ENDO 2017 Poster Presentations

Digestive Endoscopy 2017; 29(Suppl 1): 29–261

doi: 10.1111/den.12775

ENDO 2017 Poster Presentations 17.02.2017 POSTER AREA ERCP: BILIARY/PANCREAS: ENDOSCOPY: ERCP NEW TECHNOLOGY P005: DEVELOPMENT OF ACUTE PANCREATITIS PORCINE MODEL BY USING ENDOSCOPIC RETROGRADE NOXIOUS AGENT INFUSION Sung-Wook Park, Jin-Seok Park, Don Haeng Lee, Seok Jeong Digestive Disease Center, Department of Internal Medicine, Inha University School of Medicine, Incheon, Korea

AIMS: A reproducible large animal model of acute pancreatitis for the preclinical testing of medicine and endoscopic treatment is required. The aim of this study was to develop an animal model of acute pancreatitis using endoscopic methods. METHODS: This experimental study was conducted on six mini pigs. Pancreatitis models were induced by pressurecontrolled (1000 or 100 mmHg) infusion of contrast media or sodium taurocholate (TCA) into the main pancreatic duct using endoscopic retrograde pancreatography. The animals were randomly allocated into three groups: (1) contrast-induced pancreatitis. (2) 10% TCA-induced pancreatitis. (3) 20% TCA-induced pancreatitis. Injury of the pancreas was evaluated histologically. Serum amylase and lipase level were measured.

RESULTS: Endoscopic procedures were performed successfully in all animals. No technical difficulty or adverse events occurred during the procedures. Acute pancreatitis in all animals was observed on hematologic and histologic examination. There was a significant increases in serum amylase and lipase levels (>10 times of baseline level) and they observed increases in pancreatic edema formation, vacuolization of acinar cell, and hemorrhagic necrosis. Degree of pancreatitis in the TCA (the mean histologic acute pancreatitis score, 10) groups tended to be greater than contrast-induced group (6.5). An analysis of degrees of pancreatitis according to concentration of TCA showed that the higher concentration of TCA, the more severe pancreatitis was occurred (necrosis score in 20% TCA vs 10% TCA, 4 vs 2.5). CONCLUSIONS: The two endoscopic procedures described are effective and safe for creating a swine model of acute pancreatitis. We estimated that these endoscopic methods could be helpful for developing the treatment strategy of acute pancreatitis. Conflict of Interest: None declared.

P006: ENDOCLIP THERAPY OF POSTSPHINCTEROTOMY BLEEDING USING A TRANSPARENT CAP-FITTED FORWARD-VIEWING GASTROSCOPE Hyung Ku Chon, Tae Hyeon Kim Wonkwang University College of Medicine and Hospital, Iksan, Korea

AIMS: The incidence of post-endoscopic sphincterotomy (ES) bleeding is reportedly 2.0–5.0%. Among various hemostatic methods, endoclip therapy is an effective modality in gastrointestinal bleeding. However, endoclip application for post-ES hemorrhage has not been widely studied, partly because of the difficulty in placing of clips using a duodenoscope. A cap-fitted forward-viewing gastroscope can easily visualize the major papilla and overcome the technical difficulty in applying endoclips. We aimed to determine the efficacy and safety of endoclips for the treatment of post-ES hemorrhage using a capfitted forward-viewing gastroscope. METHODS: From January 2011 to December 2015, a total of 1448 endoscopic retrograde cholangiopancreatography (ERCP) procedures with ES were retrospectively assessed and followed-up. Patients with post-ES hemorrhage who did not respond to balloon compression or to spray or injection of a diluted epinephrine solution at the bleeding focus underwent endoclip therapy using a cap-fitted forward-viewing gastroscope. Bleeding patterns (oozing, pulsatile, and exposed vessel) were recorded.

RESULTS: ES-induced uncontrolled hemorrhage occurred in 57 patients (3.93%). The mean age was 68.9 14.5 years and the sex ratio (male: female) was 37 (64.9%): 20 (35.1%) in 57 patients. Of the 57 cases of hemorrhage, early uncontrolled and delayed hemorrhage occurred in 45 (3.1%) and 12 (0.82%), respectively. Visible bleeding patterns following ES were: 50 oozing (57.7%), six pulsatile (10.5%), and one exposed vessel (1.8%). Hemostasis was achieved by endoclipping using a capfitted forward-viewing gastroscope in 57 of 57 patients (100%). The median number of clips used was 1.8 (range: 1–3). No evidence of further bleeding or procedure-related complications was seen. CONCLUSIONS: We concluded that endoclip application using a cap-fitted forward-viewing gastroscope is feasible and safe, and may be an effective technique for the treatment and/ or prevention of post-ES hemorrhage. Conflict of Interest: None declared.

© 2017 The Authors. Digestive Endoscopy © 2017 Japan Gastroenterological Endoscopy Society

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Poster Presentations

P007: NEW NITINOL GALLBLADDER STENT FOR PREVENTION OF STONES MIGRATION AND IMPACTION Fred M. Konikoff1, Ivo Boskoski2, Shmuel Ben Muvhar3, Andrea Tringali2, Tsehori Jonathan4, Guido Costamagna2 1 Meir Medical Center, Kfar Saba, Israel, 2Catholic University of Rome, Rome, Italy, 3Co-founder & CEO of LithiBlock, Savyon, Israel and 4Co-founder at Lithiblock, Savyon, Israel

AIMS: Cholecystectomy is the standard treatment for gallstones but can lead to complications and even death. Gallstones become a problem requiring intervention only when blocking bile flow from the galblladder or migrate into bile ducts. The LithoBlockerTM is a patented nitinol-umbrella-like stent designed to prevent gallstones from blocking the orifice of the gallbladder and migration into bile ducts, maintaining the the gallbladder functions and bi-directional bile flow. The stent accomodates itself within the gallbladder facing its orifice upon release. The stent is inserted into the gallbladder during a standard ERCP using a conventional metalstent delivery system. To investigate the feasibility and safety of insertion and deployment of the stent into the gallbladder of pigs. Shortterm safety was evaluated. METHODS: The study protocol was approved by the hospital ethical committee. ERCP was done in 10 animals at the facility of the Catholic University of Rome, Italy. Overnight fast and abdominal ultrasound was performed to determine the size of the gallbladder (to choose the size of the stent). At the end of the follow-up period the animals were sacrificed according to international standards. The procedure was performed with a standard Olympus duodenoscope (TJF140) under fluoroscopic control and general anesthesia. After colangiography and sphincterotomy, the gallbladder was cannulated. The LithoBlockerTM stent was introduced over the same guidewire into the gallbladder with an 8Fr catheter. The stent was deployed in the gallbladder under fluoroscopic control.

RESULTS: A total of 10 procedures, eight device placements and two sham procedures were performe. No complications were observed. Mean procedure time was 20.5 min (14–37). Maximum follow-up before sacrifice was 42 days. On autopsy the stent was correctly in place in seven pigs, while it migrated completely in 1.


P008: ENDOSCOPIC INTERVENTION IN THE TERMINAL PORTION OF THE COMMON BILE DUCT Farukh Makhmadov Avicenna Tajik State Medical University, Department of Surgical Diseases No 1, Dushanbe, Tajikistan

AIMS: Improving the efficiency of endoscopic diagnosis and treatment of benign pathology of the terminal part of the common bile duct. METHODS: The study is based on the study results of endoscopic examination and treatment of 179 patients with pathology of major duodenal papilla and the terminal part of the common bile duct: choledocholithiasis (n = 57), papillostenoz (n = 34), choledocholithiasis combined with papillostenosium in (n = 82) and adenoma papillary (n = 6). Mechanical jaundice, occurred in 112 (62.6%) patients, 44 of them were older than 60 years. ERCP was performed 350 patients. In 34 (19.6%) patients with holetsistoholedoholitiasium complicated by obstructive jaundice and cholangitis, EPST with nazobiliarnium drainage was performed as the first stage of surgery on the biliary tract.

RESULTS: Endoscopic intervention in the papilla of Vater were applied 49 (27.3%) patients with external biliary fistula caused by choledocholithiasis and papillary stenosis. In 33 (18.4%) cases, EPST was made at the height of jaundice. In 19 (10.6%) patients with signs of cholangitis, EPST was completed nazobiliarnium drainage by the method developed in our clinic. In 31 (17.3%) patients during surgery after the establishment of cicatricial stenosis of major duodenal papilla and terminal part of the common bile duct was performed intraoperative antegrade endoscopic papillosphincterotomy with the endoprosthesis according to the method developed in the clinic. Complications after endoscopic papillosphincterotomy was observed in 12 (6.7%) patients. The frequency of complications after EPST ranged from 4% to 15%. According to our data the effectiveness of corrective EPST papillostenosium was - 97.2%, choledocholithiasis - 94.2%, and the phenomenon of cholangitis - 95.6%. CONCLUSIONS: Endoscopic papillosphincterotomy is less traumatic, a highly effective method of treatment of stenosis of the large duodenal papilla and choledocholithiasis. Conflict of Interest: None declared.

CONCLUSIONS: The LithoBlockerTM stent is a promising tool that could prevent gallstones from migration and impaction without major complications. Clinical trials are need to confirm this results. Conflict of Interest: None declared.




P009: ENDOSCOPIC BILATERAL SIDE-BY-SIDE METAL STENTS DEPLOYMENT ACROSS THE PAPILLA FOR MALIGNANT HILAR BILIARY OBSTRUCTION

P010: INTRAMUCOSAL TECHNIQUE VS NEEDLE KNIFE PRE CUTSPHINCTEROTOMY IN BILIARY ACCESS AT ERCP

Kazunaga Ishigaki, Hirofumi Kogure, Hiroyuki Isayama, Naminatsu Takahara, Suguru Mizuno, Saburo Matsubara, Yousuke Nakai, Minoru Tada, Kazuhiko Koike

Mahesh Goenka1, Vijay Rai1, Sanjay Mahawar2

University of Tokyo, Graduate School of Medicine, Department of Gastroenterology, Tokyo, Japan

AIMS: Endoscopic management of unresectable hilar malignant biliary obstruction (MBO) is technically challenging. The sequential side-by-side (SBS) metal stents deployment across the papilla is relatively simple at initial placement and reintervention. However, SBS deployment has potential disadvantages of overexpansion of the common bile duct and papilla, which can lead to early adverse events such as hemobilia, cholecystitis, and pancreatitis. This study was designed to evaluate the safety and efficacy of the sequential SBS metal stenting for patients with hilar MBO.

METHODS: Between June 2014 and September 2016, bilateral SBS deployment across the papilla with uncovered WallFlex Biliary RX Stent (Boston Scientific Corp., Marlborough, MA, USA) was performed in 23 patients. Technical success, clinical success, adverse events, and long-term outcomes were evaluated.

RESULTS: A total of 23 patients (13 male, a median age of 71 years) were enrolled. Endoscopic sphincterotomy was performed in all cases. Single-session and final technical success rate was 91% and 97%, respectively. Clinical success rate was 87%. The number of placed stents was two in 20 (87%) and three in 3 (13%). Early adverse events (15 mg/dL 37.3%, malnutrition-5.2%, pruritis-1% and waitlist-11.5%. PBD was performed successfully in 172 (LFU-2), ERCP-145 (83.3%), PTBD after failed ERCP-26 and EUS-BD-1, using SEMS in 103 (99-uncovered) and plastic stent (PS) in 42. Post PBD morbidity occurred in 56 (31.2%) and mortality in 4 (2.3%). Stent dysfunction occurred early (1 week) in 3 (SEMS-1, PS-2) and late (>1 week) in 21 (SEMS11, PS-10, P = 0.008) with median patency of 70 days in SEMS and 37.5 days in PS (P = 0.98). Post PBD 55.7% patients (SEMS-67, PS-30) underwent surgery (whipples-87, exploration-10) as 54 (31%) defaulted, 14 (8.6%) had metastasis and two are awaiting surgery. Postoperative complications neither differed significantly (P = 0.69) between PBD group (40.2%) and upfront surgery (52.2%) performed in 115 cases in same period, nor between SEMS (66.6%) and PS (33.3%) (P = 0.36), nor in those operated within 6 weeks (15) or beyond (82) (P = 0.47), but was significantly worse in PBD subgroup with S bilirubin >15 mg% (P = 0.035). Overall complication rate (PBD and post-operative) did not differ between PBD (54.6%) and upfront surgery (52.2%) groups, regardless of use of SEMS (P = 0.081) or if S. bilirubin >15 mg/dL (P = 0.413).

CONCLUSIONS: PBD does not appear to reduce post operative complications with a trend of worse outcomes when baseline S. bilirubin is >15 mg%. While SEMS has superior patency, it has similar outcomes as PS. Conflict of Interest: None declared.

CONCLUSIONS: Endoscopic transenteral internal drainage provides excellent long term results without the need for ERCP and transpapillary drainage. Superadded infection is a limitation of plastic stents requiring repeat endoscopic procedures. Conflict of Interest: None declared.

P024: PROSPECTIVE AUDIT OF PREOPERATIVE BILIARY DRAINAGE USING SELF EXPANDING METAL STENTS ON POST-OPERATIVE OUTCOMES IN PERIAMPULLARY MALIGNANCIES AT A TERTIARY CANCER CENTRE IN INDIA Shaesta Mehta, Prachi Patil, Mukund Virpariya Tata Memorial Centre, Digestive Diseases and Clinical Nutrition, Mumbai, India

AIMS: Evaluate the impact of preoperative biliary drainage PBD using self expanding metal stents (SEMS) on post-operative outcomes. METHODS: We analysed prospectively maintained database of 174 consecutive patients referred for PBD between January 2013 and June 2016. ERCP was upfront primary modality for PBD. The primary outcome was post-op complication rate.

RESULTS: One hundred and seventy-four patients were referred for PBD (mean age 56 years, 116 men, 58 women).

P025: ENDOSCOPIC VS LAPAROSCOPIC DRAINAGE OF PANCREATIC PSEUDOCYST/WALLED OFF NECROSIS: A RANDOMIZED CONTROLLED TRIAL Sawan Bopanna1, Pramod Kumar Garg1, Daneshwar Meena2, Devya Babu2, Rajesh Padhan1, Rajan Dhingra1, Virender Kumar Bansal2, Subodh Kumar2, Asuri Krishna2, Hemang Bhattacharya2, Mahesh Chand Misra2 All India Institute of Medical Sciences 1Gastroenterology, and 2Surgery, New Delhi, India

AIMS: Surgical and endoscopic drainage have similar efficacy for pancreatic pseudocyst drainage. No randomized controlled trial (RCT) has compared endoscopic with laparoscopic drainage for pancreatic pseudocysts. METHODS: We compared endoscopic with laparoscopic drainage in patients with pseudocysts following acute pancreatitis in a RCT. Patients with walled off necrosis (WON) containing 3 points or required surgery after adequate therapeutic intervention.

RESULTS: Total 84 patients age 31.75 13 years were

reviewed. Mean follow up was 20.5 17 months.14 (16.7%) had alcohol induced CP, six had stricture after duct disruption (7.1%) following acute exacerbation of CP and rest had idiopathic CP (77.2%).Type A pain was seen in 70 patients. Avg no. of ERP per subject - 3.2 2.57 had pancreatic strictures (length-13.3 7.2 mm) with papillary stenosis in 3, head, genu, proximal body and multiple strictures in 28, 17, 6 and 3 patients respectively. Thirty-nine patients had stones (10 0. 6 mm) of which 22 had stones and stricture.ESWL required in all of them with 10 requiring two sessions.Post ESWL complete stone clearance failed in four patients (10%). Failed cannulation in one patient (1.2%).These five patients (5.9%) were referred for surgery. Minor papilla endotherapy was required for 12 (14.3%) patients. Twenty patients (23.7%) had associated distal CBD stricture with 19 of them undergoing CBD drainage and stenting. Visual analogue score pre and post therapy were 8.25 2.2 to 3 2.6.25 (53%) of the 48 patients who had regular stent exchange are stent free (within 12– 18 months).


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CONCLUSIONS: Endoscopic drainage of CP provides excellent intermediate term results with no improvement in exocrine functions. Conflict of Interest: None declared.

ERCP: PANCREAS: ENDOSCOPY: ERCP COMPLICATIONS AND OUTCOMES P045V: COMPREHENSIVE MINIMALLY INVASIVE TREATMENT OF HEMOBILIA AFTER PERCUTANEOUS TRANSHEPATIC DRAINAGE OF BILIARY TRACT IN A PATIENT WITH PANCREATIC CANCER AND MECHANICAL JAUNDICE

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 adverse effects of the primary intervention and to avoid open surgical operation. Conflict of Interest: None declared.

P046: COMPARISON OF ENDOSCOPIC SPHINCTEROTOMY, ENDOSCOPIC PAPILLARY LARGE BALLOON DILATION, AND ENDOSCOPIC SPHINCTEROTOMY PLUS LARGE-BALLOON DILATION FOR CHOLEDOCHOLITHIASIS: A SYSTEMATIC REVIEW AND NETWORK METAANALYSIS Yu-Ting Kuo, Wei-Chih Liao, Hsiu-Po Wang

Stanislav Budzinskiy, Evgeny Gorbachev, Dmitriy Freidovich, Sergey Kapranov, Anton Zlatovratsky, Dar’ya Bakhtiozina, Inna Babkova, Evgeny Fedorov, Sergey Shapovalianz

National Taiwan University Hospital, Internal Medicine, Taipei, Taiwan, China

Pirogov Russian National Research Medical University, Moscow University Hospital N 31, Moscow, Russia

AIMS: Comparing to endoscopic sphincterotomy (EST), two methods of endoscopic papillary large balloon dilation (EPLBD) alone and EPLBD combined with EST (ESLBD) offered another alternative to deal with large or difficult bile duct stones removal in the past decade. In view of inadequate head-to-head comparison trials, the superiority and safety among these three techniques remain controversial. Therefore, we aimed to use network meta-analysis to provide evidence on comparative effectiveness for clinical decisionmaking.

AIMS: Percutaneous transhepatic biliary drainage could cause serious complications, requiring integrated management. METHODS: Patient P., 63 years old, admitted to our hospital with mechanical jaundice. Abdominal ultrasound showed a lesion in the pancreatic head with compression of common bile duct and it’s dilation up to 18 mm. Primary ERCP attempt failed. Due to that PTC with the installation of external drainage was performed. Early postoperative period was uneventful and jaundice almost resolved.

RESULTS: However, 10 days later mechanical jaundice increased again. Moreover, the hemorrhagic content appeared in the drainage with decrease in daily production of bile; level of Hb decreased from 131 to 107 g/L. We performed urgent antegrade-retrograde “rendez-vous” intervention, which showed hemobilia with large clots. We performed biliary sphincterotomy, bile ducts sanitation, inserting of biliary plastic stent and external drainage. Nevertheless within 2 days anemia increased. We suggested a trauma of the large vascular structure. At fistulography blood clots were again visualized. Attempt of the canal filling by fibrin hemostatic sponge was performed, however on cholangioscopy a fistula with an arterial vessel 0.5 mm in diameter was revealed. Urgent angiography was performed - in the field of a segmental branch of the right hepatic artery, localized in a projection of the transhepatic drainage, the erosion of contours without extravasation of contrast was visualized. The super selective catheterization of this branch with the subsequent spiral embolization was made. As a final stage of treatment plastic biliary stent was replaced by partially covered self-expanding metal stent. The patient discharged from the hospital ays later in a satisfactory condition.

METHODS: We systematically reviewed randomized controlled trials from PubMed, Embase and abstracts from international conferences to compare EST alone, EPLBD alone, and ESLBD regarding successful stone removal, mechanical lithotripsy (EML) use and overall complications. In addition to pairwise meta-analyses, mixed models for network metaanalysis was undertaken to compare the 3 procedures together. After running a network meta-analysis, we used simulations to calculate the ranking of treatment.

RESULTS: Total nine eligible articles were included for final analysis. In our result, ESLBD caused fewer EML use (OR = 0.49, 95%CI: 0.30–0.80, P < 0.001) and overall complications (OR = 0.63, 95%CI: 0.43–0.94, P < 0.001) than EST alone. Although there were no significant difference in complete stone removal, first session successful stone removal and all different kinds of complication rates between three groups, ESLBD was ranked the best successful stone removal with the least frequent use of EML and fewer of any kinds of complications. CONCLUSIONS: Both of EPLBD and ESLBD for the removal of large bile duct stones are an effective and safe approach with fewer mechanical lithotripsy use than EST alone. Conflict of Interest: None declared.

CONCLUSIONS: Thus, a comprehensive approach to diagnosis and treatment of complications allows to eliminate the




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P047: DIAGNOSTIC ERCP WITH PROPHYLACTIC PANCREATIC STENTING FOR BRANCH DUCT TYPE IPMN INCREASE THE RISK OF POST ERCP PANCREATITISΔ

AIMS: ERCP is a therapeutic approach of ampulla of Vater cancer (AVC) mainly used as palliative treatment. The aim of our study was to evaluate the results of endoscopic palliative treatment in ampulla of Vater cancer.

Eisuke Iwasaki1, Haruhiko Ogata2, Takanori Kanai1

METHODS: A retrospective study including patients with

Keio University School of Medicine 1Division of Gastroenterology and Hepatology, Department of Internal Medicine, and 2Center for Diagnostic and Therapeutic Endoscopy, Tokyo, Japan

AIMS: Despite a proven clinical risk, no study has examined the relationship between diagnostic ERCP (endoscopic retrograde cholangiopancreatography) and its impact on PEP (postERCP pancreatitis) in patients with intraductal papillary mucinous neoplasm (IPMN). We examined the relationship between diagnostic ERCP and PEP rates in patients with IPMNs. METHODS: A retrospective review was conducted of diagnostic ERCP in patients in our hospital with IPMN from 2012 to 2016.

RESULTS: A total of 67 patients underwent diagnostic ERCP for IPMN. Of these, 30 patients were diagnosed with branchtype IPMN (BD-IPMN), while 37 were diagnosed with main and mixed type IPMN (non-BD-IPMN). The cannulation and procedure success rates were 100% in both groups. BD-IPMN had a significantly higher frequency of PEP than non-BD-IPMN (16.7% vs 0.0%, P = 0.02). The mean next day serum amylase level in patients with BD-IPMN was 219 IU, which was significantly higher than the mean of 177 IU found in the non-BD-IPMN patients. The sensitivity of pancreatic juice cytology for BDIPMN was significantly lower than that for non-BD-IPMN (8.3% vs 28.6%). On univariate analysis, significant risk factors with adjusted odds ratios (OR) for the incidence of PEP were insertion of prophylactic pancreatic stent (OR=13.7, P = 0.02) and BD-IPMN (OR=8.77, P = 0.02). CONCLUSIONS: These results suggest a lower diagnostic accuracy despite a higher incidence of PEP after the diagnostic ERCP for branch duct-type IPMN than that noted for main duct and mixed type IPMN. We should avoid diagnostic ERCP with prophylactic pancreatic stent insertion in patients with branch duct-type IPMN. Conflict of Interest: None declared.

advanced AVC who underwent an endoscopic retrograde cholangio-pancreatography (ERCP) in our department in the period between January 2007 and June 2016 was performed. We investigated epidemiological, therapeutic and evolutionary parameters of each patient in addition of tumor characteristics and survival rates.

RESULTS: Thirty-three patients with AVC were included (mean age 70 years [37–85], sex ratio 1.53 (20 M/13 F)). The main circumstance of discovery was jaundice in 69.9% of cases, otherwise, it was acute pancreatitis or pain of right upper quadrant of abdomen. In 51.5% of patients, endoscopy was performed in emergency due to angiocholitis. 87.8% of patients had an endoscopic sphincterotomy with biliary stenting, the type of stent was plastic in almost all cases except one patient who had a metallic partially covered stent. Biopsies of the ampulla of Vater confirmed the malignancy in 54.5% of patients. Three patients had short-term complications (acute renal failure leading to death, heart disorders and early stent migration); late complications occurred in eight patients: stent clogging (75%) or migration (25%). Seven patients had stent exchange within 6 months of first ERCP, a new plastic stent was used in four cases and a metallic one in 3. Survival was estimated to 75% at 6 months and 50% at 12 months. CONCLUSIONS: ERCP is useful for patients with ampulla of Vater cancer, especially in palliative treatment and in case of emergency. Survival rates are acceptable provided a close follow-up and depending on stage of the disease. Conflict of Interest: None declared.

P049: RECTAL INDOMETHACIN AND PREVENTION POST ERCP PANCREATITIS. COMPARATIVE STUDY OF 189 CONSECUTIVE PATIENTS Hela Elloumi1,2, Hajer Hssine1,2, Dalila Gargouri1,2, Asma riam Sabbah1,2, Norsaf Bibani1,2, Jamel Kharrat1,2 Ouakaa1,2, Me 1

P048: ERCP RESULTS FOR PALLIATIVE TREATMENT IN ADVANCED AMPULLA OF VATER CANCER riam Sabbah1,2, Ons Gharbi1,2, Dorra Trad1,2, Dalila Me Gargouri1,2, Norsaf Bibani1,2, Asma Ouakaa1,2, Hela Elloumi1,2, Jamel Kharrat1,2 1

Habib Thameur Hospital, Gastroenterology, and 2University of Tunis El Manar, Faculty of Medicine, Tunis, Tunisia

Habib Thameur Hospital, Gastroenterology, and 2University of Tunis El Manar, Faculty of Medicine of Tunis, Tunis, Tunisia

AIMS: Rectal indomethacin, a non steroidal anti-inflammatory drug, is given to prevent pancreatitis in high risk patients undergoing retrograde cholangiopancreatogrphy (ERCP), based on findings from clinical trials. Our aim was to determine the potential value of indomethacin in the prevention of acute post ERCP pancreatitis. METHODS: We performed a prospective study over a period of 12 months [January 2015- December 2015] including 223


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ERCP. The patients were divided into two groups: group A who received 100 mg of indomethacin rectally before the procedure; group B who did not receive indomethacin. The primary outcome was the development of post ERCP pancreatitis (PEP) defined by new upper- abdominal pain, a lipase level more than 3-fold the upper limit of normal.

RESULTS: A total of 189 patients (mean age: 57 years [23– 103]; 66.6% females) underwent 223 procedures. There were no differences between the groups baseline clinical or procedural characteristics. Ninety-six patients received indomethacin before ERCP (group A). Post ERCP pancreatitis occurred in 8.3% in group A and in 3.1% in group B (P = 0.08).

CONCLUSIONS: In our prospective study, rectal indomethacin did not prevent post ERCP pancreatitis. Conflict of Interest: None declared.

STOMACH AND SMALL INTESTINE: ENDOSCOPY: CAPSULE ENDOSCOPY P050: INDICATION OF SMALL-BOWEL CAPSULE ENDOSCOPY IN PATIENTS WITH CHRONIC ABDOMINAL PAINΔ Ichiro Otani1, Shiro Oka1, Shinji Tanaka1, Makoto Nakano2, Sayoko Kunihara2, Atsushi Igawa2, Kazuaki Chayama2 Hiroshima University Hospital 1Endoscopy, and 2 Gastroenterology and Metabolism, Hiroshima, Japan

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 (n = 1), and those of non-IBS group as follows: NSAIDs ulcer (n = 3), Crohn’s disease (n = 3), eosinophilic enteritis (n = 3), IGA vasculitis (n = 1), parasitic worm (n = 1), ischemic enteritis (n = 1).

CONCLUSIONS: CE should be considered for non-IBS patients with high CRP in the CAP patients. Conflict of Interest: None declared.

P051: IN THE INTERPRETATION OF CAPSULE ENDOSCOPY, IS THERE A ROLE FOR PRE-READER? Sang Yup Lee, Jung Min Lee, Byeong Kwang Choi, In Kyung Yoo, Seung Han Kim, Jae Min Lee, Hyuk Soon Choi, Eun Sun Kim, Bora Keum, Yoon Tae Jeen, Hoon Jai Chun, Hong Sik Lee, Chang Duck Kim Korea University College of Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul, Korea

AIMS: Capsule endoscopy (CE) has become an important tool for the diagnosis of small bowel disease. A major problem of CE is that it is time consuming to read one case. Although few previous studies have showed a supporting role of Pre-Reader in the reading of CE, it remains controversial. In this study, we aimed to show the complement role of low experienced endoscopy trainee (VCE 100) reviewed each case individually with reference to the filled up assessment form. Same videos, which didn’t include the Pre-Readers assessment form were reviewed by another high experienced endoscopists too. We evaluated the agreement, missed lesion, overcalled, and reading time between two expert groups.

RESULTS: At assessment form, which filled up by Prereader, agreement (A)/missed lesion (M)/overcalled (O) were observed in 72.3%/ 8.9%/18.8% respectively. The agreement rate was high in vascular and ulcerative lesions, On the other hand, overcalled lesion was high in neoplastic, especially polypoid lesion. Pre-reader´s assessment form supported experts to get more abnormal findings (detection rate was improved by 10~20%), however final diagnosis was not changed. Pre-reader´s assessment form added more information as well as decreased expert´s time consuming significantly. CONCLUSIONS: Pre-reader added more information on capsule endoscopy, even though the final diagnosis was not changed. Also, a group of pre-reader could decrease the time




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consuming. In this study, we showed complement role of prereader in the reading of CE. Conflict of Interest: None declared.

P053: FACTORS RELATED TO DIAGNOSTIC YIELD OF CAPSULE ENDOSCOPY IN OBSCURE GASTROINTESTINAL BLEEDING WITH NEGATIVE CT ENTEROGRAPHY

P052: A STUDY OF OPTIMAL TIME INTERVAL FOR STARTING CAPSULE ENDOSCOPY AFTER SMALL BOWEL PREPARATION

Hwa-Sun Park, Seong Ran Jeon, Hyun Gun Kim, Tae Hee Lee, Jun-Hyung Cho, Junseok Park, Joon Seong Lee, Jin-Oh Kim

Byeong Kwang Choi, Jung Min Lee, Sang Yup Lee, In Kyung Yoo, Seung Han Kim, Jae Min Lee, Hyuk Soon Choi, Eun Sun Kim, Bora Keum, Yoon Tae Jeen, Hong Sik Lee, Hoon Jai Chun, Chang Duck Kim Korea University Anam Hospital, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul, Korea

AIMS: Capsule endoscopy (CE) has been considered as a gold standard for investigation of the small bowel. It has been challenging to determine the optimal preparation of the small bowel for accurate capsule endoscopy examination. Especially, there is a paucity of research for different time interval after small bowel preparation. The objective of this study was to evaluate the suitable preparation-to-CE time interval. METHODS: Total 24 inpatients who underwent CE from August 2014 to June 2015 were retrospectively investigated. Patients receiving bowel preparation by 3-L PEG-Asc were divided 2 group. The one (Group A) began capsule endoscopy within 3 h after bowel preparation and the other (Group B) began capsule endoscopy 3 hours later after bowel preparation. Also, we compared cleansing score scale through each 2, 4, 5 h group. The quality of small bowel preparation was assessed using a previous cleansing score system. Representative frames were serially selected at 5-min intervals and scored by assessment of two properties (proportion of luminal visibility and extent of obscuration). Completion rate, Small bowel transit time, overall Diagnostic yield, frequency of identified mucosal abnormalities was evaluated between two groups.

RESULTS: Thirteen patients were in group A and 11 patients were in group B. A < 3-h preparation to capsule endoscopy time was higher mean score than a >3-h interval cleansing (2.35 vs 2.08). The frequency of mucosal abnormalities and diagnostic yield were similar between the two groups in criteria of 2, 3, 4 and 5 hours after preparation. There was significant difference of completion rate, small bowel transit time between two groups according to time interval.

CONCLUSIONS: A shorter interval (3 h) between end of bowel preparation and start of capsule endoscopy. Conflict of Interest: None declared.

Soonchunhyang University, Digestive Reserch, Digestive Disease Center, Division of Gastroenterology, College of Medicine, Seoul, Korea

AIMS: Capsule endoscopy (CE) is currently recommended as first-line study in the evaluation of obscure gastrointestinal bleeding (OGIB), some consider CT enterography as a complementary test to CE. This study evaluated the factors of improvement the diagnostic yield of CE in patients with OGIB and negative CT enterography. METHODS: We reviewed the medical records related to forty one patients with OGIB who was performed CT enterography and CE from July 2007 to February 2013, focusing our attention with negative CT enterography. CT enterography is defined including enteral phase with or without neutral enteric contrast material. We evaluated forty one patients with negative CT enterography and analyzed the detection rate of CE obscure bleeding focus. Cases were divided into two groups; first group who had diagnostic finding of CE (n = 26) and second group who had non-diagnostic finding of CE (n = 15). The two groups were compared retrospectively.

RESULTS: Twenty six of 41 (63.4%) CE studies had diagnostic results. Mucosal lesions (75.6%) were the most common findings, followed by nonspecific findings (17.1%) and tumorous lesions (2.4%). In comparison between patients with and without diagnostic CE finding, mucosal lesion (Odds 21.660, CI 2.269– 206.755; P = 0.008) and using of neutral enteric contrast material before CT enterography (Odds 15.828, CI 1.005– 249.350; P = 0.050) were significant factor for diagnostic CE finding. CONCLUSIONS: In the patients with OGIB and negative CT enterography, using of neutral enteric contrast material before CT enterography is possible to improve the diagnostic yield of the CE. Conflict of Interest: None declared.

P054: CAPSULE ENDOSCOPY IN OBSCURE GI BLEEDING: A LARGE EXPERIENCE FROM A TERTIARY CARE CENTER Rajesh Gupta, P. Manohar Reddy, Nitin Jagtap, Hrushikesh Chaudhari, Mohan Ramchandani, D. Nageshwar Reddy Asian Institute of Gastroenterology, Dept of Medical Gastroenterology, Hyderabad, India


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AIMS: To evaluate the diagnostic yield of capsule endoscopy and its impact on clinical management in obscure GI bleeding. METHODS: The medical records of the patients from Jan 2003

endoscopy provides important clinical information for patients with IBD - CD, with an excellent tolerability and safety profile. Conflict of Interest: None declared.

to July 2016, who underwent Capsule endoscopy (CE) for evaluation of obscure GI bleeding at Asian Institute of Gastroenterology, Hyderabad, India, were reviewed. The Video Capsule Endoscopy system of Given Imaging (Yoqneam, Israel) was used in all cases.

P056: CAPSULE ENDOSCOPY: INDICATIONS, FINDINGS AND COMPLICATIONS AMONG PATIENTS WITH SUSPECTED SMALL BOWEL LESIONS

RESULTS: Overall, 1457 capsule endoscopy examinations

Dina Ali Mohammed1,2, Abdelmounem Abdo1,2

were performed during the above mentioned period. 76% (1107 of 1457) CE examination were done for evaluation of obscure GI bleeding. The diagnostic yield of CE in overt GI bleeding was 86%, whereas it was 47% in occult GI bleeding. The most common positive findings were Nonspecific/ NSAID erosions or ulcers, AVM, worms and SB tumours. CE had an overall impact on clinical management in 79% patients. < 1% patients had retention of CE.

CONCLUSIONS: Capsule endoscopy is a safe and effective imaging modality for evaluation of OGIB. It occupies an important place in algorithmic approach to management of Obscure GI Bleeding. Conflict of Interest: None declared.

P055: CAPSULE ENDOSCOPY IN INFLAMMATORY BOWEL DISEASE - CROHN’S DISEASE: A LARGE EXPERIENCE FROM A TERTIARY CARE CENTER P. Manohar Reddy, Rajesh Gupta, Nitin Jagtap, Rupa Banerjee, D. Nageshwar Reddy Asian Institute of Gastroenterology, Department of Medical Gastroenterology, Hyderabad, India

AIMS: To evaluate the diagnostic yield of Capsule Endoscopy and its impact on clinical management in Inflammatory Bowel Disease - Crohn’s disease (IBD - CD). METHODS: The medical records of the patients from Jan 2003 to July 2016, who underwent Capsule Endoscopy (CE) at Asian Institute of Gastroenterology, Hyderabad, India, were reviewed. The Video Capsule Endoscopy system Of Given Imaging (Yoqneam, Israel) was used in all cases.

RESULTS: Overall, 1457 Capsule Endoscopy examinations were performed during the above mentioned period. 16.3% (237 of 1457) CE examination were done for evaluation of IBD, 84.8 % (201 of 237) were suspected CD and 15.2 % (36 of 237) were previously diagnosed cases of CD. Overall positive yield of CE in IBD was 61.6 % (146 of 237). Focal ulcers and nodularity was seen in 63 % (92 of 146; out of which 20 were ulcerated strictures) and focal erosions in 37 % (54 of 146). CE had an overall impact on clinical management in 74% patients. < 4 % patients had retention of CE.

1

National Center for Gastro Intestinal and Liver Diseases Ibnsina Specialized Hospital, Gastroenterology, and 2WGO Khartoum Training Centre, Khartoum, Sudan

AIMS: Until a few years back, evaluation of small bowel pathology was unsatisfactory because of the inability to completely visualize the small bowel mucosa with the available endoscopic and radiological techniques. Since the advent of capsule endoscopy at the beginning of the millennium it became the gold standard for the diagnosis of most diseases of the small intestine. METHODS: This study was conducted to assess the indications, findings, and complications of CE among patients with suspected small bowel lesions. It also studies the effect of small bowel transit time on the diagnostic yield of the capsular endoscopy. It included a total of 119 patients with suspected small bowel disease receiving CE examination at the department of gastroenterology of Ibn-sina and Fedail hospitals in Sudan, during the period from January 2010 to June 2011.

RESULTS: One hundred nineteen patients, 69 male and 50 female were enrolled. The main indication for capsule endoscopy was OGIB, the CE identified the cause of bleeding in 39 of the 61 patients (63.9%) presented with obscure GI bleeding and Angiodysplasia was the main finding in such patients comprising 31.1%. Other indications for CE were small bowel diarrhea in 21 patients (17.6%), evaluation of Crohn’sdisease in five patients (4.2%), chronic abdominal pain in 18 patients (17.6%), nonresponding celiac disease in three patients (2.5%) and four patients presented with suspicion of small bowel malignancy. CONCLUSIONS: Capsule endoscopy is a very useful diagnostic tool, especially in the presence of a strong suspicion of small bowel pathology. The duration of small bowel transit time during capsule endoscopy does not affect its diagnostic yield. Repeating the capsule endoscopy in patients with a previously negative capsule examination and a high suspicion of small bowel pathology may reveal additional finding in the majority of patients. Conflict of Interest: The 2nd author Dr Abdo has business in capsule endoscopy.

CONCLUSIONS: CE is a very important tool for diagnosis and therapeutic decision making in patients with IBD - CD. Capsule




P057: THE ROLE OF CAPSULE ENDOSCOPY IN SUDANES PATIENTS WITH OBSCURE GASTROINTESTINAL BLEEDING

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CONCLUSIONS: Capsule Endoscopy in tropical regions may

1

have interesting endoscopy findings Confirmation with histopathology and video reporting of such findings is very essential. Conflict of Interest: The presenter has business with capsule Endoscopy company.

AIMS: To study diagnostic yield of CE; compare it with international data and look for etiology of obscure gastrointestinal bleedin.

STOMACH AND SMALL INTESTINE: ENDOSCOPY: ENDOSCOPIC THERAPY OF THE SMALL INTESTINE

METHODS: This is retrospective and prospective study

P059V: SPHINCTER PRESERVING ENDOSCOPIC REMOVAL OF THE MAJOR DUODENAL PAPILLA NEUROENDOCRINE TUMOR: FROM SCREENING EGD TO MORPHOLOGICAL EXAMINATION

Abdelmounem Abdo1, Ismat Elnour2 National Center for Gastrointestinal and Liver Diseases, Gastroenterology, and 2Alnilain University, Khartoum, Sudan

enrolling 60 patients with OGIB referred for capsule endoscopy after negative conventional endoscopies. The patients were counseled and agreed with consent. Capsule results were downloaded in computer workstation with MiRoview-intromedic, Korea and images are analyzed by gastroenterologist with experience in CE.

Stanislav Budzinskiy, Evgeniy Fedorov, Zalina Galkova, Daria Bakhtiozina, Evgeniy Gorbachev, Inna Babkova, Sergey Shapovalianz

RESULTS: The capsule endoscopy diagnostic yield was 75% (45 patients). With diagnostic yield higher in occult bleeding than obscure bleeding 79% and 72% respectively. The etiologies of OGIB in positive CE patients were: 17 patients (37.8%) of patients have angioectasia, 16 patients (35.6) has ulcer, inflammations were noticed in 9 patients (8.9%), malignancy found in 5 patients (11%) and in 3 patients (6.7) miscellaneous diagnoses.

AIMS: Careful observation of the second part of the duodenum during routine EGD is quite important and enables detection of rare lesions.

CONCLUSIONS: Our study has high diagnostic yield which is

METHODS: A young, 33 years old woman, admitted to our

Pirogov Russian National Research Medical University, Moscow University Hospital N 31, Moscow, Russia

comparable to international data. The leading cause of etiology of OGIB is mainly ulcer and angioectasia. Conflict of Interest: the non presenting author has business with capsule Endoscopy company.

hospital without complaints in October 2015 for endoscopic resection of a major duodenal papilla (MDP) lesion. In 2012 at preoperative check-up for cholecystectomy in another hospital an upper endoscopy was performed revealing a lesion of MDP. In 2015 the patient still didn’t have any symptoms, but decided to undergo control endoscopy. Tendency to growth was found.

P058V: CAPSULE ENDOSCOPY VIDEOS FINDINGS IN SUDANESE PATIENTS CONFIRMED BY HISTOLOGY

RESULTS: Preoperative duodenoscopy showed the 20 mm non-epithelial lesion located at the MDP frenulum, just below the lower semicircle of the papilla. Due to this fact, we performed EUS and found that the lesion rises from the 2nd layer and it is hypoechoic, homogeneous and shows no expansion on common bile duct or main pancreatic duct. Thus the preliminary diagnosis was neuroendocrine tumor (NET) of MDP without spreading on ductal systems. We performed snare electroexcision of the lesion en-block in ERCP operating room in case of the need to extend to papillectomy. Early postoperative period was uneventful. The diagnosis of non-functioning duodenal NET was confirmed by histological examination and immunohistochemistry. The patient discharged from the hospital 3 days after the procedure; 5 months later no complaints, a control EGD revealed no local recurrence, no significant deformity of the MDP.

Abdelmounem Abdo National Centre for Gastrointestinal and Liver Diseases, Gastroenterology, Khartoum, Sudan

AIMS: To demonstrate some cases of capsule endoscopy diagnosis confirmed by histopathology or laboratory. METHODS: To study five cases of capsule endoscopy four of them underwent surgery and histopathology obtained from the patient records.

diagnosis

RESULTS: Five cases who underwent capsule endoscopy studied, four of them underwent surgery. Two surgeries done due to capsule retention and the two other surgeries done as part of the management. The diagnosis after histopathology were, Crohn’s disease, Carcinoid tumor and intestinal tuberculosis. The 5th case was a renal transplanted patient, Numerous of live moving worms were found in the small bowel and colon in capsule endoscopy, the stool examination reviled H Nana.

CONCLUSIONS: Accurate EUS helps to identify the lesion and to clarify the volume of intervention. Localization of the lesion close to MDP without spreading on its orifice and ductal systems makes it feasible to perform endoscopic excision saving the sphincter of Oddi. However, the long-term


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oncological results should be evaluated carefully to identify whether endoscopic removal is safe and effective. Conflict of Interest: None declared.

P060: CLINICAL OUTCOMES OF ENDOSCOPIC FULLTHICKNESS RESECTION FOR NON-AMPULLARY DUODENAL SUBMUCOSAL TUMORS Jiaxin Xu, Mingyan Cai, Pinghong Zhou, Meidong Xu, Yunshi Zhong, Chitchoon Lim Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China

AIMS: Duodenum has been regarded as the most challenging site among the gastrointestinal tract for endoscopic fullthickness resection (EFTR). We herein present our experience and assess the efficacy of EFTR in management of nonampullary duodenal submucosal tumors (NADSMTs). METHODS: We retrospectively analyzed 23 patients who underwent EFTR in our center for NADSMTs between February 2012 and July 2015. Patient demographics, tumor characteristics, and treatment outcomes, especially adverse events including delayed bleeding, postoperative peritonitis or retroperitoneal abscess, were observed.

RESULTS: Among the 23 patients, 12 were male and 11 were female. The median age was 52 years (range, 31–81). The mean maximal diameter was 1.36 0.48 cm (range, 0.6–2.4 cm). Fourteen tumors were located in duodenal bulb (60.9%), six in the conjunction of duodenal bulb and descending duodenum (26.1%), and three in descending duodenum (13.0%). All lesions achieved en bloc resection (100%). In one case, the closure by endoscopy was suspended due to tumor extraluminal growth pattern and large defect after EFTR, and the patient was referred to emergency neoplasty. In the 22 successful cases, no adverse event related to EFTR occurred during the median hospital stay of 5.5 days (range, 2–10 days). Pathologic results included seven gastrointestinal stromal tumors (30.4%), seven ectopic pancreas (30.4%), four neuroendocrine tumors (17.4%), and one lipomyoma (4.3%), hamartoma (4.3%), liomyoma (4.3%) respectively. The remaining two were spindle cell tumors (8.7%) without immuohistochemical stain. Except five patients were lost and one patient die of myocardial infarction ten months after EFTR, during the median follow-up time of 16 months (range, 7–48 months), no tumor residual, recurrence or metastasis were found.

P061: WIDE-FIELD ENDOSCOPIC MUCOSAL RESECTION IN THE SMALL BOWEL: DOUBLEBALLOON ENTEROSCOPY FACILITATED DEFINITIVE MANAGEMENT OF A VERY RARE CAUSE OF JEJUNAL INTUSSUSCEPTION Nikolaos Koukias1,2, Erasmia Vlachou1,2, Alberto Murino1,2, George Goodchild1, Peter Wylie3, Tu Vinh Luong4, Edward Despott1,2 1

Royal Free Unit for Endoscopy, Gastroenterology, University College of London (UCL) Institute for Liver and Digestive Health, 3Royal Free Hospital, Radiology, and 4 Royal Free Hospital, Histopatology, London, UK 2

AIMS: Jejunal adenomas (JA) are exceedingly rare lesions with potential for malignant transformation and resultant poor prognosis. Management is usually surgical. Double-balloon enteroscopy (DBE) allows minimally invasive diagnosis and curative management. This case highlights the usefulness of DBE facilitated wide-field endoscopic mucosal resection (EMR) of a large sessile JA presenting with intermittent subacute small bowel obstruction caused by intussusception. METHODS: A 46-year-old woman with a 4-year history of intermittent cramping abdominal pain underwent a CT enterography demonstrating a 10 cm jejunal intussusception (15 cm distal to the ligament-of-Treitz) with a suspicious lead-point at the intussusceptum. At diagnostic anterograde DBE (under conscious sedation), a large (6 cm) sessile jejunal polyp was identified as the culprit lesion; it’s location was marked by a submucosal tattoo of sterile India ink and histopathology of biopsies confirmed this to be a JA with low-grade dysplasia (LGD).

RESULTS: At a second pre-planned therapeutic anterograde DBE, performed under general anaesthesia, the intussusception was reduced using the double-balloon technique and the JA was successfully resected by wide-field EMR without complications. Histopathology of the resected JA only showed LGD and confirmed complete resection. A 3rd follow-up anterograde DBE performed two months later did not reveal any evidence of recurrence. CONCLUSIONS: Our report describes the definitive role of DBE as a minimally invasive approach for the diagnosis, curative management and follow-up of a very rare and pre-malignant cause of jejunal intussusception. Conflict of Interest: None declared.

CONCLUSIONS: EFTR is a promising technique in treating NADSMTs with an excellent efficacy. However, the procedure should be performed by experienced endoscopists with great caution, because of the anatomical features of duodenum which contribute to the high challenge of EFTR. Conflict of Interest: None declared.




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P062: CYANOACRYLATE INJECTION THERAPY OF SMALL BOWEL VARICES BY DOUBLE-BALLOON ENTEROSCOPY (DBE): A TERTIARY CENTRE EXPERIENCE

P063: SMALL BOWEL OBSTRUCTION CAUSED BY A MIGRATED OBALON GASTRIC BALLOON: NONSURGICAL MANAGEMENT BY ANTEROGRADE DOUBLE-BALLOON PAN-ENTEROSCOPY

Alberto Murino1, Nikolaos Koukias1, Erasmia Vlachou1, Konstantinos Mantzoukis1, Katie Planche2, James O’Beirne1, David Patch1, Edward J. Despott1

Alberto Murino1, Shamindra Direkz1, Erasmia Vlachou1, Nikolaos Koukias1, George Goodchild1, Peter Wylie2, Mark I. Hamilton1, Charles D. Murray1, Edward J. Despott1

1

The Royal Free Hospital and University College London (UCL) Institute for Liver and Digestive Health, Royal Free Unit for Endoscopy, and 2The Royal Free Hospital and University College London (UCL) Institute for Liver and Digestive Health, Department of Radiology, London, UK

1

The Royal Free Hospital and University College London (UCL) Institute for Liver and Digestive Health, Royal Free Unit for Endoscopy, and 2The Royal Free Hospital and University College London (UCL) Institute for Liver and Digestive Health, Department of Radiology, London, UK

AIMS: Small bowel varices (SBV) occur as a consequence of

AIMS: The Obalon® intragastric balloon (Obalon Therapeutics,

portal hypertension and may result in life-threatening mid-gut bleeding. First line management usually involves radiological intervention (RI) (e.g. TIPSS, stenting of occluded mesenteric veins +/- embolisation of culprit varices). In cases where RI is impossible, management options become very limited. This case series evaluated the usefulness of DBE facilitated cyanoacrylate injection of SBV.

CA, USA) is a space occupying device designed for weight loss treatment. The balloon is enclosed in a swallowable capsule, which once in the stomach is inflated through an orogastric catheter. This case highlights the usefulness of DBE for the removal of migrated Obalon® intragastric balloon.

METHODS: Retrospective review of DBE facilitated cyanoacrylate injection of SBV at our institution (December 2015 to August 2016). Demographic, clinical, endoscopic and radiological findings, interventions and follow-up data were analysed.

RESULTS: Seven DBEs were performed in five patients (three women, median age: 73-years). Four patients had previous surgery (hemi-hepatectomy (n = 2); SB resection (n = 2)); one patient had a history of intra-abdominal sepsis in childhood causing portal vein thrombosis. No radiological or surgical options were deemed feasible in any case. SBV were diagnosed at capsule endoscopy and triple phase CT mesenteric angiography. At DBE, a total of 10 nests of SBV were identified and injected with cyanoacrylate glue. There were no haemorrhagic or embolic complications but one patient developed an infection of a congenital urachal cyst, which was treated successfully with antibiotics. All patients underwent DBEs via the anterograde route and one patient required bi-directional DBE for treatment of both proximal and distal SBV and another patient required a 2nd anterograde DBE for treatment of further patent proximal SBV. At 30-day follow-up post-therapy, only one patient had experienced a mild recurrence of mid-gut bleeding. CONCLUSIONS: Cyanoacrylate injection therapy of SBV at DBE appears to be a safe and effective management strategy for this condition when other first-line options are not feasible. Conflict of Interest: None declared.

METHODS: A 46-year-old-woman presented with small bowel obstruction (SBO) two months after placement of two Obalon® balloons. CT confirmed SBO caused by a partially deflated balloon migrated into the ileum; the other balloon remained inflated in-situ within the stomach. After 72-hours of conservative management, sudden symptom worsening warranted intervention. For avoidance of surgery, we performed an anterograde DBE.

RESULTS: The first Obalon was deflated and extracted to enable friction-free DBE. The enteroscope was then inserted down to the distal ileum (an estimated depth of 6.4 m from the pylorus) where the second partially-deflated retained balloon was identified, approximately 20 cm proximal to the ileo-caecal valve (ICV). It was then completely deflated by aspiration through an endoscopic injection needle and carefully pushed through the ICV into the ascending colon (AC) with endoscopic graspers. No strictures were encountered during the uncomplicated pan-enteroscopy. The obstructive symptoms resolved completely and the balloon passed in the stools two days later. CONCLUSIONS: Migration of partially-deflated gastric bariatric balloons into the SB is a recognised uncommon complication which may warrant surgical intervention. This is only the second reported case of management of gastric balloon related SBO by DBE; we achieved it through anterograde panenteroscopy with endoscopic deflation of the impacted balloon and advancement of this through the ICV into the AC. The anterograde route was the only DBE-approach possible with SBO and an unprepared colon. Our case highlights the usefulness of DBE for the potential avoidance of surgery in such cases. Conflict of Interest: None declared.


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P064V: AN UNUSUAL DUODENAL SUBMUCOSAL CYSTADENOMA: A CASE REPORT Ting Guo, Yuyong Tan, Deliang Liu The Second Xiangya Hospital of Central South University, Department of Gastroenterology, Changsha, China

AIMS: Duodenal submucosal cystadenoma is a very rare disease, which almost hadn´t been reported before. This report aims to show this rare disease and its therapy. METHODS: Here we present a case of duodenal submucosal cystadenoma being treated with endoscopic submucosal dissection (ESD). A 56-year-old man referred to our department seeking for a treatment of a mass in the duodenal bulb. The mass was discovered by endoscopy in a routine examination. The patient reported no abdominal pain, nausea or vomiting and denied any history of carcinoma. The physical examination were unremarkable. Laboratory testing showed the blood cell counts, tumor markers (carcinoembryonic antigen and carbohydrate antigen 199), pepsinogen and fecal occult blood test were all within the normal ranges. White light endoscopy showed a spherical mass measuring 4 cm in diameter with clear border, which extended from the pyloric canal to anterior wall of the duodenal bulb. The mucosa had no erosions and ulcers. Endoscopic ultrasonography revealed a submucosal mass with heterogeneous echogenicity and cystic structure. Computed tomography (CT) showed a solid cystic mass with rim enhancement and lack of enhancement in cystic spaces. The patient received ESD uneventfully and a 4 9 392 cm mass was removed. The biopsies showed duodenal submucosal cystadenoma.

RESULTS: During a follow-up of six months, the patient recovered well without any complications and endoscopy examination did not find any residual lesion or recurrence.

the SEMS for the benign stricture is not well studied. So this study evaluated the feasibility of partially covered SEMS as an initial treatment method for the benign pyloric stricture.

METHODS: We enrolled the patients who were diagnosed as duodenal ulcer with gastric outlet obstruction from Dec 2011 to May 2016. There were 15 Patients, who were treated by the partially covered SEMS. Men were twelve. Mean age was sixtytwo (46–86).

RESULTS: To facilitate the placement of SEMS, we dilated the stricture in six cases using the CRE balloon (18 mm) just before placing the SEMS. But we didn’t use the CRE balloon for most of cases. We used the partially covered Hanaro stent, which was used for six cases, and partially covered Niti-S stent for others. As adverse events, patients suffered from the SEMS migration during the follow up period in four cases. And we couldn’t remove the stent in two cases because of the luminal growing into the stent. But the gastric outlet obstruction symptom score was much improved (1 ? 3) after placing the SEMS. CONCLUSIONS: We experienced fifteen cases of placing the partially covered SEMS for the benign duodenal stricture. Most of them improved the gastric outlet symptom and it is possible to remove the previous installed partially covered stent. It is feasible to place the SEMS for the benign pyloric stricture. Conflict of Interest: None declared.

P066V: ENDOSCOPIC RESECTION OF A LARGE BRUNNER´S GLAND HAMARTOMA FROM THE DUODENUM IN A PATIENT PRESENTING WITH AN UPPER GASTROINTESTINAL BLEED Tiffany Poon1, Rish Pai2, Dora Lam-Himlin2, Rahul Pannala1 Mayo Clinic, Gastroenterology, and 2Mayo Clinic, Laboratory Medicine and Pathology, Phoenix, USA 1

CONCLUSIONS: This case reminds us that the heterogenous solid cystic mass derived from submucosa should raise the suspicion for duodenal submucosal cystadenoma. As cystadenomas have a potential risk of malignancy when they arise from other common organs and the large mass may lead to symptoms of obstruction, the excision should be performed for treatment of duodenal submucosal cystadenoma. ESD is a safe and effective method. Conflict of Interest: None declared.

AIMS: We present a case of an otherwise healthy 46-year-old male who initially presented with melena stools, low hemoglobin and fatigue. He underwent upper endoscopy and was discovered to have a large pedunculated polypoid lesion in the first portion of the duodenum. Initial biopsies revealed chronic duodenitis. Our aim is to illustrate a method for endoscopic removal of large polypoid lesions in the duodenum. METHODS: Endoscopic resection was performed to remove a

P065: THE FEASIBILITY OF PARTIALLY COVERED SELF-EXPANDABLE METAL STENT FOR THE BENIGN PYLORIC STRICTURE Jun Heo, Seung Jae Yeo, Min Kyu Jung Kyungpook National University School of Medicine, Internal Medicine, Daegu, Korea

AIMS: The self-expandable metal stent (SEMS) is wildly used for the malignant gastrointestinal obstruction. However, using

5 cm polyp. Epinephrine 1:10 000 was injected into the polyp initially to reduce polyp size. An Endoloop was placed at the base of the stalk to occlude feeding vessels and reduce bleeding. The polyp was removed in two pieces with a snare and retrieved with a Roth net. The resection was performed 5 mm to 6 mm above the ligature to allow spontaneous sloughing of remaining polypoid tissue.

RESULTS: Pathology subsequently confirmed a Brunner’s gland hamartoma. The large polypoid Brunner´s gland hamartoma was successfully resected in two pieces. The patient had


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 no further bleeding and will be seen in three months to be reassessed.

CONCLUSIONS: Brunner’s gland hamartomas (BGH) are a rare benign tumor of the duodenum. These lesions are an uncommon cause of upper gastrointestinal bleeding and duodenal obstruction. BGHs are most commonly found in the duodenal bulb accounting for 70% of cases, 26% in the second portion, and 4% in the third portion. Lesions arising in portions of the duodenum distal to the first portion tend to bleed more due to stress and vascular compromise from gastrointestinal motility. Most commonly, they are asymptomatic and incidentally found. BGH usually presents in middle-aged patients and is equally distributed amongst females and males in incidence. These lesions can be large and endoscopic removal is the treatment of choice. Conflict of Interest: None declared.


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polyps. No intraoperative or delayed perforations were observed. Melena was encountered in one patient and was managed without emergent endoscopic intervention.

CONCLUSIONS: BSP for duodenal tumors of FAP patients is feasible and effective for relatively large lesions with high-grade dysplasia. Long-term outcome of BSP, including local recurrence and prognosis, should be monitored. Conflict of Interest: None declared.

P068V: DUODENAL DUPLICATION CYST COMMUNICATING WITH PANCREATIC DUCT ENDOSCOPIC MANAGEMENT Prakash Zacharias1, Shibi Mathew2, John Mathews2, M. Prashant2, P Maya2, Aby Somu2, Mathew Philip2 1

P067: FEASIBILITY OF BIPOLAR SNARE POLYPECTOMY FOR DUODENAL TUMORS IN FAMILIAL ADENOMATOUS POLYPOSIS PATIENTS Kazuya Inoki, Takeshi Nakajima, Satoru Nonaka, Hiroyuki Takamaru, Masau Sekiguchi, Masayoshi Yamada, Seiichiro Abe, Taku Sakamoto, Haruhisa Suzuki, Shigetaka Yoshinaga, Takahisa Matsuda, Ichiro Oda, Yutaka Saito National Cancer Center Hospital, Endoscopy Division, Tokyo, Japan

PVS Hospital, Gastroenterology, and 2PVS Hospital, Kochi, India

AIMS: Efficacy of endoscopic management in duodenal duplication cyst producing recurent pancreatitis. METHODS: Eight years old boy with recurrent episodes of acute pancreatitis underwent evaluation. He was found to have a cystic lesion in the head of pancreas region with a prominent pancreatic duct. He underwent MRI. MRCP and CT abdomen which showed a cystic lesion in D2 with focally dilated pancreatic duct in head region. There was a suspicion of communication of the cyst with pancreatic duct. He later underwent duodenoscopy, EUS, ERCP & Pancreatic stenting and later deroofing of the the cyst wall endoscopically. The cyst fluid amylase was very high. After deroofing the cyst wall, endoscopic evaluation of the cyst wall revealed intestinal mucosa from which biopsies were taken. A small fistulous opening was seen within the cyst through which the previously placed pancreatic duct stent was visualized confirming the communication. Biopsies taken from the inside of cyst and cyst wall confirmed duodenal duplication cyst.

AIMS: Management of duodenal as well as colorectal tumors is imperative in patients with familial adenomatous polyposis (FAP). Because the risk of complications during or after endoscopic resection (ER) of duodenal tumors is higher than that of complications associated with stomach or colorectal lesions in general, ER should be carefully performed. We hypothesized that the use of bipolar devices would reduce damage of the muscularis and result in better short-term outcome. The aim of this study was to evaluate the feasibility of bipolar snare polypectomy (BSP) for duodenal tumors in FAP patients.

RESULTS: Following the procedure, there was no further episodes of pancreatitis.

METHODS: A total of 10 FAP patients who underwent BSP for

CONCLUSIONS: This is a rare case of duodenal duplication

duodenal tumors at our hospital between October 2013 and August 2016 were retrospectively analyzed based on their clinicopathological features. The indications of duodenal tumors in FAP patients were adenomas of >20 mm in size, lesions of >10 mm in size with biopsy-confirmed high-grade dysplasia or carcinoma, and multiple tumors.

cyst communicating with pancreatic duct, producing recurrent pancreatitis, which was managed endoscopically. Conflict of Interest: None declared.

RESULTS: A total of 17 endoscopic treatments were performed and 117 duodenal tumors were resected. The median patient age at the time of initial treatment was 42 years (range: 20–64), and the median size of the largest tumor in each procedure was 12 mm (range: 9–40). Of the 84 lesions that were pathologically evaluated, seven had high-grade dysplasia (intramucosal carcinoma in the Japanese classification), 74 were tubular adenomas, and three were non-neoplastic mucosal


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STOMACH AND SMALL INTESTINE: ENDOSCOPY: GASTRIC NEOPLASIA P069: NOVEL FORCEP STRIP TECHNIQUE OF ENDOSCOPIC RESECTION FOR SUBMUCOSAL TUMORS IN THE STOMACH Hoon Jai Chun, In Kyung Yoo, Jung Min Lee, Byeong Kwang Choi, Sang Yup Lee, Seung Han Kim, Jae Min Lee, Hyuk Soon Choi, Eun Sun Kim, Yoon Tae Jeen, Hong Sik Lee, Chang Duck Kim Korea University Anam Hospital, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul, Korea

AIMS: Resection of submucosal tumors by means of endoscopy has been reported using a variety of techniques. However, lesions originating from the muscularis propria layer are unlikely to be resected completely and safely. Here, we report the first series describing the new technique of endoscopic resection for submucosal tumors of the stomach using the simple and safe forcep strip technique. METHODS: Endoscopic submucosal tumor resection using hot biopsy forcep was attempted in ten consecutive patients in clinical indications for lesion removal. Following injection around the submucosal tumor, the adjacent mucosa or submucosa was grasped with the forceps and pulled away forming a “tent”. Electrocoagulating current was applied for dissection of tissue. For repeating described process, the tumor was dissected from the muscularis propria layer and then carefully removed using forcep.

RESULTS: All of the ten patients that underwent Forcep Strip Technique for the gastric submucosal tumors were successful, with the complete resection rate of 100%. There was no major bleeding and the procedure time was reduced compared to the conventional methods. No complications occurred and followup was unremarkable. It is possible to resect submucosal tumor any part of the stomach (fundus, cardia, body). On histology, all tumors were resected completely (eight gastrointestinal stromal tumor, two leiomyomas). CONCLUSIONS: Forcep Strip Method appears to be an easy, safe, and effective procedure for treatment of gastric submucosal tumor originating from the muscularis propria layer. Conflict of Interest: None declared.

AIMS: The Gastric Cancer Treatment Guidelines (2014) in Japan indicate endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) based on data derived from surgically resected EGC specimens without lymph node metastasis. However, the risk of recurrence after non-curative ESD has remained uncertain after additional surgery and after follow-up by observation. We compared the characteristics, clinical course and prognosis of patients after non-curative ESD. METHODS: Between August 2006 and July 2015, 347 patients with 399 differentiated-type EGC lesions underwent ESD at Aichi Cancer Center Aichi Hospital. According to the Japanese guidelines, 48 patients were treated by non-curative resection. Twelve patients with a positive lateral resection margin as the only non-curative factor were excluded. The remaining 36 patients were assigned to either group A (n = 23) that underwent additional surgery according to the guidelines or to group B that was followed up by observation (n = 13). The clinicopathological characteristics, outcomes and prognosis of the two groups were retrospectively compared.

RESULTS: Age, sex, tumor location, gross type, tumor size, histological margin, venous invasion and depth of invasion did not significantly differ between the two groups. Only lymphatic invasion significantly differed (P = 0.003). The median follow-up after ESD was 42.6 (range 12–118.8) months. Residual gastric cancer was identified in surgical specimens from six patients in group A. Recurrent lesions and death from gastric cancer did not occur in group A during follow-up, whereas endoscopy identified recurrent gastric lesions at six and 13 months after ESD in two patients in group B, who then underwent additional surgery. Overall survival did not significantly differ between the two groups (P = 0.392). CONCLUSIONS: Additional surgery prevented the recurrence of gastric cancer. However, careful observation after ESD might be also acceptable depending on the general physical and psychological condition of patients. Conflict of Interest: None declared.

P071: APPLICATION OF A NOVEL STRATEGY FOR ENDOSCOPIC SUBMUCOSAL DISSECTION IN TREATMENT OF GIANT SUBCARDIAC SUBMUCOSAL TUMORS Bingtuan Liu, Han Chen, Guoxin Zhang

P070: COMPARISON OF PROGNOSIS BETWEEN ADDITIONAL SURGERY AND OBSERVATION AFTER NON-CURATIVE ENDOSCOPIC SUBMUCOSAL DISSECTION FOR GASTRIC CANCERΔ 1

1

1

Shinya Kondo , Takayoshi Fujita , Yoshie Tsuzuki , Yu Sobajima1, Hidemi Goto2 1

Aichi Cancer Center Aichi Hospital, Gastroenterology, Okazaki, and 2Nagoya University Graduate School of Medicine, Gastroenterology, Nagoya, Japan

The First Affiliated Hospital of Nanjing Medical University, Nanjing, China

AIMS: Subcardiac submucosal tumors (SCSMTs) are among the most technically difficult lesions for endoscopic submucosal dissection (ESD).We developed a novel ESD strategy “mucosareserved aproach method”(MRAM). The aim of the study was to assess the safety and efficacy of normal ESD and MRAM in SCSMTs resection.


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 METHODS: A retrospective observational study was conducted, investigating the clinical records of 23 patients with submucosal tumors in the subcardiac region, who underwent ESD between March 2012 and March 2016. Patients were categorized into two groups, group A were treated by conventional ESD procedure, group B by a novel improved ESD procedure, which was conducted by preserving the overlying mucosa Giant tumor was defined as tumor with a maximal diameter of at least 3 cm. The clinicopathological data, therapeutic outcomes, en bloc rates and procedure-related complications were further analyzed.

RESULTS: Mean operation time of group B was longer than group A. Leiomyomas of the two group were both in the majority. Nine of ten cases in group B had wounds sutured, meanwhile only 46.2% wounds in group A was sutured. So the average number of clips used during the operation in group B was 10, more than that in group A. One patient in group A had postoperative stenosis, and no serious complications occurred in group B. The en bloc resection rates were similar in two groups. All the patients underwent the operation successfully and postoperative rehabilitation satisfactorily. CONCLUSIONS: Our study demonstrated that ESD, no matter improved MRAM or not, is a safe and effective method for subcardiac submucosal tumors. It has a high en bloc resection rate. MRAM can reserved the overlying mucosa of SCSMTs, so it is a time-consuming but also a more safe and effective process. Conflict of Interest: None declared.

P072: THE COMPARISON OF SUBMUCOSAL TUNNELING ENDOSCOPIC RESECTION AND ENDOSCOPIC FULL-THICKNESS RESECTION FOR GASTRIC FUNDUS SUBMUCOSAL TUMORS


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time, pathohistological results, hospital stay and cost (P > 0.05). However, patients who received EFTR had a longer suture time and needed more clips to close the gastric wall defect (P < 0.05). No recurrence was noted in the STER and EFTR groups during a mean follow-up of 12.1 and 22.8 months, respectively.

CONCLUSIONS: The treatment efficacy between STER and EFTR for treating gastric fundus SMTs was comparable, but STER takes advantages over EFTR in a shorter suture time and less clips to close the gastric wall defect. Conflict of Interest: None declared.

P073: TUMOR SIZE AND LYMPHATIC-VASCULAR INVOLVEMENT RELATE TO LYMPH NODE METASTASIS IN PATIENTS WHO HAVE TYPE 3 GASTRIC NEUROENDOCRINE TUMORΔ Kaoru Nakano1, Toshiaki Hirasawa1, Ken Namikawa1, Noriko Yamamoto2, Junko Fujisaki1 Cancer Institute Hospital Ariake 1Gastroenerology and 2 Pathology, Tokyo, Japan

AIMS: The treatment for a patient who has a type 3 gastric neuroendocrine tumor (NET) without distal metastasis is generally a gastrectomy with lymph node dissection. The indication of local resection, including endoscopic resection and Laparoscopy and Endoscopy Cooperative Surgery (LECS), does not have just one point of view. The presence of lymph node metastasis is the most important prognostic factor for patients after local resection. The aim of this study was to identify the clinicopathological factors related to lymph node metastasis. METHODS: Overall, 23 type three gastric NETs were treated

Yuyong Tan, Tianying Duan, Xuehong Wang, Liang Lv, Yuqian Zhou, Yi Chu, Jirong Huo, Deliang Liu

from January 2007 to December 2015. Therapeutic efficacy and follow-up results were retrospectively evaluated.

The Second Xiangya Hospital of Central South University, Changsha, China

RESULTS: The mean size of the gastric NETs was 7.9 5.1 mm. NET grades according to the WHO classification are as follows: grade 1, 6 and grade 2, 17. In all cases, tumor invasion limited to the submucosal layer. Endoscopic resection was performed in nine cases, and an additional operation was performed in one case because of an incomplete endoscopic resection. LECS was performed in two cases, and surgical resection with lymph node dissection was performed in 10 cases. Two cases were followed up by observation. Three cases were positive for lymph node metastasis. During the follow-up period (33; 1–84 months), no recurrence and mortality were observed. There was a significant correlation between tumor size larger than 11 mm and lymphatic-vascular involvement, with an increased risk of lymph node metastasis. There was no significant difference of the metastatic rate between WHO grade 1 and 2.

AIMS: To compare the safety and efficacy of submucosal tunneling endoscopic resection (STER) and endoscopic fullthickness resection (EFTR) for treating gastric fundus submucosal tumors (SMTs). METHODS: We retrospectively collected the clinical data about patients with gastric fundus SMTs who received STER or EFTR at our hospital from April 2011 to May 2016. Epidemiological data (gender, age), tumor size, procedure-related parameters, complications, length of stay, cost and follow-up data were compared between STER and EFTR.

RESULTS: A total of 43 patients were enrolled, and 15 of them received STER, while the other 28 cases received EFTR. There was no significant difference between the two groups in terms of gender, age, tumor size, en bloc resection rate, operation

CONCLUSIONS: Tumor size larger than 11 mm and lymphatic-vascular involvement were related to lymph node metastasis. It is considered that patients who had lesions less than 10 mm in size, limited submucosal layer, and none


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exhibited lympho-vascular could be treated by local resection without node dissection. Conflict of Interest: None declared.

P074: ENDOSCOPIC TREATMENT OF NEUROENDOCRINE TUMORS OF THE STOMACH Iliya Perfilyev, Urii Kuvshinov, Leonid Cherkes, Ivan Karasev, Nataliya Matvienko, Olga Malikhova, Guram Ungiadze Blokhin Russian Cancer Research Center, Moscow, Russia

AIMS: Evaluation of the effectiveness of endoscopic methods of gastric NETs (G-NETs) treatment. METHODS: At N.N. Blokhin Russian Cancer Research Center 64 patients with G-NETs received endoscopic treatment between 2000–2015. We used such methods as mechanical excision with coagulation, EMR and ESD. The criterion for the patients selection was type of the tumor. We chose flat elevated (O-IIa) or polypoid (O-Ip) type of G-NETs with histological grade 1 (G1) or 2 (G2) and with submucosal invasion less than sm2 according EUS signs.

RESULTS: In one case EMR wasn´t radical, according to the results of histology of block after resection. The gastrectomy was performed to patient. One patient had continued growth of the tumor after EMR in the postresection area. Re-resection was performed for nine patients because of metachronous foci of G-NET. Time remission from the moment after EMR to identify new foci of NET was from 9 months to 6 years. The average period amounted to 2 years 3 months. We didn’t have any complications such us bleeding and perforation.

CONCLUSIONS: Endoscopic methods of treatment G-NETs are effective and safe. However, hypergastrinaemia is the reason for the appearance of new NET in the stomach. Therefore, these patients need control after endoscopic treatment. Conflict of Interest: None declared.

P075: ENDOSCOPIC DIAGNOSTICS OF NEUROENDOCRINE TUMORS OF THE STOMACH Iliya Perfilyev, Urii Kuvshinov, Olga Malikhova, Vera Delektorskaya, Nataliya Matvienko, Ivan Karasev, Leonid Cherkes, Guram Ungiadze

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 METHODS: From 2000 to 2015 a complex endoscopic research, which includes a standard examination, NBI, chromoscopy, ZOOM-endoscopy and EUS was performed for 76 patients with G-NETs. Female 57 (75%), male 19 (25%).

RESULTS: As the result of the research three macroscopic forms of G-NETs were dedicated: 1. Flat elevated (22.4%). 2. Polypoid (67.1%). 3. Infiltrative (10.5%). Pathognomonic signs by the first and the second forms were vasodilatation and deformation of subepithelial vessels, caused by the production of histamine by tumor cells; as well as hyperplastic transformation of epithelium due to the stimulation of gastrinomas. Pathognomonic signs, which are typical only of G-NETs, were absent by infiltrative form. The macroscopic picture corresponded to the same one as by gastric cancer. Flat elevated and polypoid forms of G-NETs were located only in the body and in the proximal part of the stomach. By infltrative form 2 of 8 tumors are revealed in the gastric anthral part. By the first and the second forms in all cases histological gradation corresponded to G1 and G2, by the third form - to G3. CONCLUSIONS: Appliance of qualifying endoscopic methods allows us to reveal pathognomonic criteria by different macroscopic forms of G-NETs and to diagnose with high cinfidence highly varied versions of G-NETs, by which the selection method is endoscopic ablation. Conflict of Interest: None declared.

P076V: GASTRIC LEIOMYOSARCOMA REVEALED BY BLEEDING riam Sabbah1,2, Dalila Gargouri1,2, Hela Elloumi1,2, Asma Me Ouakaa1,2, Raja Jouini2,3, Heithem Zaafouri2,4, Norsaf Bibani1,2, Dorra Trad1,2, Anis Ben Maamar2,4, Achraf Debbiche2,3, Jamel Kharrat1,2 1 Habib Thameur Hospital, Gastroenterology, 2University of Tunis El Manar, Faculty of Medicine, 3Habib Thameur Hospital, Pathology, and 4Habib Thameur Hospital, Surgery, Tunis, Tunisia

AIMS: Leiomyosarcomas are mesenchymal tumors who usually affect the uterus and small intestine. Primary leiomyosarcoma of the stomach is rare representing 1% of all malignant gastric tumours and only few cases have been reported. METHODS: We report a case of primary gastric leiomyosar-

Blokhin Russian Cancer Research Center, Moscow, Russia

coma stomach revealed by bleeding in a 63 years old women.

AIMS: Elaboration of endoscopic criteria for diagnostics of gastric NETs (G-NETs) and evaluation of the correlation between macroscopic versions and the histological grade (criterion G). Revelation of visual pathognomonic signs of G-NETs. Dedication of macroscopic forms of G-NETs and comparative evaluation of their histological versions.

RESULTS: A 63-years-old woman with no history was referred to our department for gastric bleeding with a low hemoglobin level (6.4 g/dL). After resuscitation and transfusion, upper endoscopy showed an ulcerated gastric submucosal tumor of 8 cm. Laboratory tests, including tumor markers, revealed no abnormal results. CT scan found the gastric tumor and revealed no apparent metastasis. Mucosal biopsy revealed a tumor proliferation made of spindle cells with high mitotic activity (20 /


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 CFG). In immunohistochemistry: cells express neither the pancytokeratin nor CD45. CD117 (c Kit) and DOG 1 were negative except for few cells having a dendritic morphology identical with cells of Cajal. The smooth muscle actin was expressed intensely and diffuse. Patient underwent surgery (total gastrectomy) and the histological examination of the tumor confirmed high grade gastric leiomyosarcoma (differentiation 2, necrosis 0, mitosis 3). Outcome was favorable after surgery.

CONCLUSIONS: Primitive gastric leiomyosacroma is rare, usually revealed by occult bleeding and it very rarely can manifest as massive gastrointestinal bleeding such as in our observation. The endoscopic ultrasound with biopsy is the examination of choice for the diagnosis with a sensitivity of 97%. Histologically, these lesions, however, remain difficult to distinguish from gastrointestinal stromal tumors. Surgery is the only curative treatment. Prognosis depends on the size of the tumor histological grade, infiltration and parietal visceral metastases with a mean five-year survival of 22%. Conflict of Interest: None declared.

P077: A CASE OF GASTRIC CANCER WITHOUT H. PYLORI INFECTION AND MUCOSAL ATROPHY Hirokazu Yamaguchi, Michio Kaminishi, Yuichi Takeda Showa General Hospital, Gastrointestinal Surgery, Kodaira, Japan

AIMS: We have experienced a case of an intestinal type of gastric cancer without background of mucosal atrophy. So called gatric type of cancer is rare, so we report this case. METHODS: The patient was 63 years old male. Endoscopic examination in a health center revealed an ulcerative lesion in the upper site of the stomach, however pathological examination did not show malignancy. Follow up endoscopic examination found another lesion in the lower site of the stomach and pathological examination revealed it was an intestinal type of cancer. Still we suspected the famer lesion was malignant, so we performed diagnostic ESD for the previous lesion. At the same time, we tried lifting up of the later lesion. We could not lift it up by sub-mucosal injection, so we judged there was no indication of ESD. More over pathological result for the famer lesion said it was an intestinal type of cancer and invaded muscle layer. We finally performed laparoscopic total gastrectomy.

RESULTS: In this patient, H. pylori infection was negative and atrophic area of gastric mucosa was restricted at the antrum. H. pylori, class-I carcinogen for gastric cancer, causes atrophic gastritis, and most of gastric cancer are developed with a background of atrophic mucosa. Some of gastric cancer is developed without H. pylori infection, mainly in cardiac area. In this case, both of lesions were located at non-atrophic area. So we supposed these were so called gastric type of cancer, and developed without intestinal metaplasia.


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CONCLUSIONS: Gastric type of cancer is rare. We will report this rare case with the results of mucus staining. Conflict of Interest: None declared.

P078: EVALUATION OF PATIENTS WITH TYPE 1 GASTRIC NEUROENDOCRINE TUMORS Ken Namikawa, Toshiaki Hirasawa, Sho Shiroma, Shoichi Yoshimizu, Kazuhisa Yamaguchi, Tomoki Shimizu, Yusuke Horiuchi, Akiyoshi Ishiyama, Toshiyuki Yoshio, Yorimasa Yamamoto, Tomohiro Tsuchida, Junko Fujisaki Cancer Institute Hospital, Gastroenterogy, Koto-ku, Japan

AIMS: This study aimed to evaluate the clinical outcome of type 1 gastric neuroendocrine tumors (T1-GNETs). METHODS: Twenty-six patients with T1-GNETs who were diagnosed and treated at our hospital from 2005 to 2016 were retrospectively reviewed.

RESULTS: The median age of all patients was 57.6 years (range, 37 85 years), and the ratio of male to female patients was 16:10. Serum gastrin levels ranged from 600 to 9100 pg/ mL (mean, 3841 pg/mL). The mean diameter of the largest tumors was 5.8 mm (range, 2–18 mm). These tumors were located in the gastric body (n = 25) and fornix (n = 1). Based on the 2010 World Health Organization classification, 22 patients had an NET G1 and four had an NET G2. The patients underwent endoscopic surveillance (n = 11), endoscopic resection (n = 7), or surgical resection (n = 8). Surgical resection included distal gastrectomy (n = 5), partial resection (n = 2), and total gastrectomy (n = 6). Intramucosal invasion was found in two patients, submucosal (SM) invasion in nine patients, and muscularis propria (MP) invasion in one patient. Among patients with capillary invasion, two had lymphatic invasion and two had venous invasion. In addition, SM invasion was found in three patients, MP invasion in one, G1 in one, and G2 in three, with mean tumor diameters of 5, 8, 12, and 12 mm, respectively. At the end of follow-up, the survival rate was 100%, with no evidence of metastases. CONCLUSIONS: Our study suggested that endoscopic surveillance and endoscopic resection are valid options for managing T1G-NETs of 35 kg/m2), the presence of obesity-related problems, and failure with conventional treatments for at least 6 months. Inflation of balloon varied between 600–650 mL saline. Intravenous antiemetic, PPI and spasmolytic drugs were given to control post-insertion nausea for 24 h. A standard 1200 Kcal diet was prescribed after dietitian´s consultation. Balloon was kept for 6 months and then removed endoscopically. Any morbidity, complications, BMI and weight loss were evaluated. Data were expressed as mean SD. Statistical analysis was performed by means of Student´s t-test, and Shapiro Wilk’s test; P < 0.05 was considered significant.

P116V: TECHNIQUE TO DIFFICULT EXTRACTION OF GASTRIC BALLOON: VEGETABLE OIL AND ENDOSCOPIC SCISSOR Sergio Barrichello1, Thiago Ferreira de Souza1, Eduardo Teixeira2, Eduardo Hourneax de Moura3, Grecco1, Andre ~ Manoel Galvao1 , ABC Medical School, Bariatric Endoscopy, Santo Andre Brazil, 2ABC Medical School, Bariatric Endoscopy, Orlando, USA and 3University of Sao Paulo Medical School, ~ o Paulo, Brazil Endoscopy, Sa 1

RESULTS: 30 patients (16 M, 14 F) with mean age of 33 years (22–48) were included after pre-procedure evaluation. 28 patients were eligible for review after 6 months; Mean weight loss was 21.2 9.05 (3–56 kg). Mean initial weight was 125.8 37.5 (102 to 236 Kg) and it dropped to 104 25.9 (82 to 180 kg) (P < 0.05) 6 months later. Mean pre-procedure BMI was 43.6 3.6 (37.6 to 50 kg/m2) while 6 months later it dropped to 37.7 4.2 (P < 0.05). 100% of the patients complained of severe nausea, vomiting, epigastric discomfort


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 and retrosternal burning, resulting in early removal of the balloon at day 7 in two patients. In 82% patients, esophagitis (grade III to IV) and diffuse gastric erosions were present at the time of withdrawal of balloon.


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cycle of weight loss, intestinal obstruction as well as other SMA complications. Conflict of Interest: None declared.

CONCLUSIONS: Intragastric balloon is associated with successful weight loss. Although severe morbidity can occur, but it provides a good means of weight reduction in conjunction with dietary measures and exercise. Conflict of Interest: None declared.

STOMACH AND SMALL INTESTINE: ENDOSCOPY: OTHER IMAGING TECHNIQUES OF THE STOMACH AND SMALL INTESTINE P118: SUPERIOR MESENTERIC SYNDROME: A CASE OF A 23 YEAR OLD WOMAN WITH DISSEMINATED TUBERCULOSIS Milben Malbog, Marichona Naval, Felix Domingo, Maria Eileen Pascua, Michael Chu East Avenue Medical Center, Internal Medicine, Quezon City, Philippines

AIMS: Superior Mesenteric Artery Syndrome is a condition of proximal intestinal obstruction caused by compression of the third portion of the duodenum by the SMA. It is a rare disorder with 0.013–0.3% incidence and 33% mortality rate. It has been reported to be associated with many conditions, however, association between SMAS and Tuberculosis had been reported rarely. METHODS: Clinical Presentation: A case of 23 year-old female with TB Meningitis and PTB maintained with anti Koch’s presented with progressive symptoms of gastrointestinal obstruction. On PE, she was cachectic with BMI of 16.1 kg/ m2. EGD showed luminal narrowing at D2 and D3 junction with no intraluminal obstruction. Abdominal CT scan showed narrowing of the third portion of duodenum as it passes in between the aorta and SMA, aortomesenteric angle of 24˚ and distance of 5 mm.

RESULTS: Diagnosis and Management: Patient satisfied the following: dilated duodenum at SFA, external compression at EGD and compression of third part of duodenum by the SMA with aortomesenteric angle of 24˚ by CT. Initially started on conservative management with nasogastric decompression, hyperalimentation and correcting fluid and electrolytes. However, conservative measures were unsuccessful prompting referral to Surgery for tube jejunostomy insertion.

P119: STOMACH VOLUME ESTIMATION WITH 3DIMENSIONAL CT GASTROGRAPHY FOR ENDOSCOPIC BARIATRIC TREATMENT Seung Han Kim, Hoon Jai Chun, Jung Min Lee, Sang Yup Lee, Byeong Kwang Choi, In Kyung Yoo, Jae Min Lee, Hyuk Soon Choi, Eun Sun Kim, Bora Keum, Yoon Tae Jeen, Hong Sik Lee, Chang Duck Kim Korea University College of Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul, Korea

AIMS: Endoscopic bariatric treatment may provide a minimal invasive alternative for surgical procedures in the treatment of obesity. Because several endoscopic treatments for obesity employs volume restriction mechanism, it is important to define anatomic factors of stomach in the obese patients for endoscopic bariatric treatment. But, there is no objective tool which could assess the structural component of the stomach and few literature regarding proper measurement of the stomach in patients with obesity. The aim of study was objective estimation of individual stomach. METHODS: 93 patients with different degrees of obesity were compared using 3-dimensional CT gastrography. Measurements included total volume of distended stomach, abdominal diameter and abdominal fat volume (visceral fat and subcutaneous fat). Patients’ baseline characteristics and laboratory findings were collected. We performed statistical analysis.

RESULTS: Stomach volume measured by 3-dimensional CT gastrography ranged from 268 to 751 mL. In obese patients, stomach capacity was increased than non-obese patients. It presented 572 301.60 mL in patients with BMI ≥25 kg/m2, 438.56 163.43 mL in patients with BMI 38.3_C) and upper abdominal pain or tenderness after ESD, with or without symptoms of peritoneal irritation were defined as having post ESD coagulation syndrome. Follow up endoscopy was performed at 3 months after the endoscopic therapy and rated as ulhealed if the ulcer was in A1 to H2 rated by Sakita-Miwa stage.


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RESULTS: In total of 200 sessions, we applied endocut mode for 116 cases (58%) and swift mode at for 84 cases (42%). The demographic data between the two groups were not significantly different. Total of 16 post ESD coagulation syndromes were notified. Multivariate analysis revealed adoption of swift mode (OR 6.90, 95%CI: 1.83–25.92) and malignant pathology (OR 5.93, 95%CI: 1.46–24.02) was related post ESD coagulation syndrome. Ulcer healing rate judged at 3 months after ESD tended to be delayed for endocut mode, even though it was not statistically significant.

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 gastric varices, 3 injections of adrenaline and one clip for bleeding ulcer.

CONCLUSIONS: In our study, etiologies of gastrointestinal bleeding were dominated by peptic ulcers and portal hypertension. Endoscopic hemostasis was achieved in one quarter of patients. Upper endoscopy had a diagnostic rentability of 90% that could be raised by systematic injection of erythromycin before endoscopy. Conflict of Interest: None declared.

CONCLUSIONS: Mode of electrical current may be related to the incidence of post-ESD coagulation syndrome or ulcer healing after gastric ESD. Conflict of Interest: None declared.

P131: THE EFFICACY ANALYSES OF PERSONALIZED BISMUTH-CONTAINING ANTI- HELICOBACTER PYLORI QUADRUPLE THERAPIES BASED ON PATIENT’S PREVIOUS ANTIBIOTIC TREATMENT

P130: UPPER ENDOSCOPY DURING GASTROINTESTINAL BLEEDING: EXPERIENCE OF A DEPARTMENT DURING 2015

Fen Wang, Chun Yue, Xiaoming Liu, Nanfang Qu, Jin Peng, Lingzhi Yuan

riam Sabbah1,2, Hela Elloumi1,2, Norsaf Bibani1,2, Dorra Me Trad1,2, Asma Ouakaa1,2, Ala Ouni1,2, Nawel Bellil1,2, Dalila Gargouri1,2, Heithem Zaafouri2,3, Dhafer Haddad2,3, Anis Ben Maamar2,3, Jamel Kharrat1,2 1

Habib Thameur Hospital, Gastroenterology, 2University of Tunis El Manar, Faculty of Medicine, and 3Habib Thameur Hospital, Surgery, Tunis, Tunisia

AIMS: Prognosis of upper gastrointestinal bleeding depends on the comorbidities of the patient, etiology, but also the quality and rapidity of the management. The aim of our study is to evaluate the different etiologies of HDH, the diagnostic and therapeutic performance of upper endoscopy for hemostasis. METHODS: A retrospective study during 2015 including all upper endoscopies done for gastrointestinal bleeding was performed. Upper endoscopy was made on patients with stable hemodynamic status sometimes requiring red blood cell transfusion. Time when upper endoscopy was performed, different objectified bleeding lesions, and endoscopic hemostasis techniques were noted.

RESULTS: During the study period, 110 upper endoscopies were performed for bleeding. Endoscopy was performed without sedation in 73 patients. Time of endoscopy was 12 h in 70% of cases (n = 77). Endoscopy was not contributive in 11 patients (10%) due to the presence of blood in the stomach requiring new endoscopy the next day. 28 patients were under gastrointestinal aggressive treatment. After upper endoscopy, portal hypertension was found in 43 patients: esophageal varices in 81% of cases, followed by gastric varices in fourteen cases. 42 patients had gastro duodenal ulcer located in the bulb in 65% of cases. The ulcers were classified Forrest I (n = 8), Forrest II (n = 11), Forrest III (n = 18). Furthermore, in 19 cases of esophagitis was objectified. Mallory Weiss syndrome was noted in 2 patients. Endoscopic hemostasis was made in 25% of cases: 18 ligation of esophageal varices, 5 glue injections for

Third Xiangya Hospital of Central South University, Changsha, China

AIMS: To investigate eradicating rates of H. pylori by quadruple regimen composed of bismuth, PPI, and two different combinations of antibiotics based on patient’s previous antibiotics treatment. METHODS: H. pylori infected patients (n = 213) were allocated into three medication groups based on past antibiotics medicating history. Patients in group A (n = 44) had no antibiotics medicating history and were administered with PPI (Esomeprazole Enteric-coated tablets) and Livzon triple (Clarithromycin tablets, Tinidazole tablets, and Bismuth Potassium Citrate Tablets). Group B patients (n = 35) had the history of other antibiotics medication but neither Amoxicillin nor Cclarithromycin use, and were treated with PPI, Amoxicillin Capsules, Clarithromycin tablets, and Colloidal Bismuth Tartrate capsules. Patients (n = 134) who underwent failures of H. pylori therapy or had taken multiple antibiotics before were included in group C: PPI, Doxycycline Hyclate Enteric-coated capsules, Furazolidone tablets, and Colloidal Bismuth Tartrate capsules were taken. The 14-day program was applied to all patients and the adverse effects of drugs were observed. 13C urea breath tests were conducted after the course of treatment (defined as at lease 4-week withdrawal antibiotic and 2-week withdrawal PPI) and the eradicating rate in three groups were analyzed.

RESULTS: The intention to treat (ITT) analysis revealed no significant difference of H. pylori elimination among three groups (P > 0.05): eradicating rate in group A was 81.8% (6 patients loss of follow-up, 1 patient withdraw for adverse events, 1 patient unsuccessful), group B was 80% (5 patients loss of follow-up, 1 patient withdraw for adverse events, 1 patient unsuccessful), group C was 88.1% (7 patients loss of follow-up, 3 patients withdraw for adverse events, 6 patients unsuccessful). The pre-protocol (PP) analysis showed 97.30%, 96.55%, 95.16% H. pylori eradication in three groups and no significant difference either (P > 0.05).


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 CONCLUSIONS: The personalized H. pylori therapies gain the satisfactory outcomes based on patient’s antibiotic history. Conflict of Interest: None declared.


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P133: ENDOSCOPIC PYLOROMYOTOMY VIA GASTRIC SUBMUCOSAL TUNNEL DISSECTION: A PROMISING TECHNIQUE FOR GASTROPARESIS Zhining Fan, Kexin He, Li Liu, Xiang Wang, Min Wang

P132: ACUTE UPPER GASTROINTESTINAL BLEEDING IN INDIA: PATIENT CHARACTERISTICS, DIAGNOSES AND OUTCOMES


Shivaram Prasad Singh1, Manoj Kumar Sahu2, S. P. Mishra3, Manu Tandan4, Mahesh Goenka5, V. G. Mohan Prasad6, Philip Augustine7, Rajkumar Wadhwa8, Varghese Thomas9, B. S. Satyaprakash10, B. V. Tantry11, Shrikant Mukewar12, V. K. Mishra13, Sujoy Pal14, S. K. Sinha15

AIMS: Pyloroplasty has been the most common treatment for the pyloric diseases. But it is still associated with complication of leakage, post-operational stenosis and general anesthesia. Therefore, the development of minimally invasive but reliable method is highly desired. Inspired by the peroral endoscopic myotomy to treat achalasia, the novel technique of endoscopic pyloromyotomy has been designed. The aim of this study is to investigate the feasibility and efficacy of endoscopic pyloromyotomy via gastric submucosal tunnel dissection.

1 SCB Medical College, Cuttack, 2IMS & SUM Hospital, Bhubaneswar, 3Motilal Nehru Medical College, Allahabad, 4 Asian Institute of Gastroenterology, Hyderabad, 5Apollo Gleneagles Hospitals, Kolkata, 6VGM Hospital, Coimbatore, 7 Renai Medicity Hospital, Cochin, India, 8Vikram Jyoth Hospital, Mysore, 9Calicut Medical College, Calicut, 10M S Ramaiah Medical College, Bengaluru, 11KMC Hospital, Mangalore, 12Midas Institute of Gastroenterology, Nagpur, 13 Gastro and Liver Hospital, Kanpur, 14All India Institute of Medical Sciences, New Delhi, and 15Post Graduate Institute of Medical Education and Research, Chandigarh, India

AIMS: Gather comprehensive data on the profile of upper gastrointestinal bleeding in India. METHODS: Multi-center survey by the ISG UGI Bleed Taskforce. Prospective data collection on the profile of UGI bleeds from March 2015 to May 2016.

RESULTS: Data on 2698 patients (median age 42 years) collected from 254 GI centers. Majority of were males (82%) and male: female ratio was 4.6:1. The most common presentation was hematemesis followed by melena. 44% had underlying chronic liver disease and 23% other associated co morbidities. Predominant etiology was variceal (44%), 30% ulcer disease predominantly in the East. 39% of patients underwent endoscopy within 24 h of presentation, only 1.4% with combination endotherapy. 5% had rebelled. 2% and 1% of all UGI bleeds required Radiologic and Surgical interventions respectively. On 30 days follow up, the overall mortality was 2.7%, 40% from non bleed related causes.

METHODS: The 5 pigs were studied for the procedure. The pyloromyotomy via the submucosal tunnel dissection was performed as the follows: (1) the incision site of mucosa was defined on the posterior gastric antral wall 5 cm proximal to the pylorus; (2) saline solution mixed with norepinephrine and methylene blue was topically injected for submucosal lifting; (3) 1–2 cm mucosal incision in longitudinal length was made to create the submucosal tunnel entry; (4) The submucosal layer was carefully disassociated until pyloric muscular layer was identified; (5) 1–2 cm pyloromyotomy were performed; (6) After endoscope withdrawal, mucosal defect were closed with clips. Pigs were euthanized and necropsies were performed.

RESULTS: Dissection of pylorus muscle was successful in the pigs. Bleeding was limited during the procedure. No complication of perforation was observed. CONCLUSIONS: The endoscopic gastric submucosal tunnel dissection technique was feasible and effective for pyloromyotomy. It is also easy to perform and minimally invasive for clinical application. Further studies need to perform for confirming the safety and efficacy on the human, and the clinical advantages other than traditional techniques. Conflict of Interest: None declared.

CONCLUSIONS: Variceal bleed is the commonest etiology in most parts of India, except the East, where ulcer disease is predominant. Compared to West the patients are younger. Endoscopic hemostasis was extremely successful and only 3% required radiologic and surgical interventions. Combination modality of endotherapy was used only in 1.4% of patients. Until and unless, we have comprehensive data, we can neither plan management strategies nor recommend any practice guidelines to have a meaningful impact on mortality. Conflict of Interest: None declared.


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STOMACH AND SMALL INTESTINE: ENDOSCOPY: PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) AND JEJUNOSTOMY (PEJ) P134: CAN THE PEG BECOME THE NUTRITION CARE TO TURN ORAL Tohru Itoh, Ken Kawaura, Kazu Hamada, HIdekazu Kitakata, Sadahumi Azukisawa, Rika Kobayashi Kanazawa Medical University, Gastroenterological Endoscopy, Uchinada, Japan

AIMS: Percutaneous Endoscopic Gastrostomy (PEG) is increasing because of the rapid aging society and recommendation of home care in Japan. The reports that the nutritional status of the PEG patients are few reports. Therefore, we investigated whether or not the nutritional status was improved. METHODS: 202 patients treated PEG between March 2001 and December 2014 were collected for the present study. We have compared the total cholesterol, triglyceride, total protein, albumin, and PNI (prognostic nutrition index) before and after (1 to 3 months) the PEG.

RESULTS: The blood analysis of the total cholesterol, triglyceride, total protein, albumin, and PNI (prognostic nutrition index) before and after (1 to 3 months) the PEG were no change. Statistically significant differences were not observed. CONCLUSIONS: When we think that the case is not ingested it or the case that may come to have difficulty in oral intake in future seems to be indicated for the PEG getting together in to boil the Seldinger/Direct method. Also, the significance of the PEG is thought to think from the nutrient plane for physiological supplementation and the route of administration securing of drug. Conflict of Interest: None declared.

was used and the Fujinon 4450 processor. The equipement was provided by Sofmedica Romania.

RESULTS: Mean (standard deviation [SD]) age of patients was 60 (20) years; most (56 %) of them were men. Contrarily to most studies with TCEs we used the endoscope as a diagnostic and therapeutic tool for all the procedures performed in our unit and not only for the esophageal conditions. Of the procedures performed, 42 % were therapeutic. Hemostasis with needle injection, clips, polipectomies, PEGgastrostomies, esophageal stenting, dilations were routinely performed, without complications. The most important advantage of TCE was the ability to pass esophageal stenosis and placement of percutaneous endoscopic gastrostomy (PEG), stents for esophageal tumors and even inspection of ileal and colonic stenosis (post surgery or in Crohn’s disease). CONCLUSIONS: In everyday clinical practice, the Fujinon TCE has specific advantages over conventional endoscopes because of its small caliber. The main advantages are introduction of high-grade strictures, introduction of fistulas, including PEG fistula and increased patient comfort. The endoscopist should appreciate these advantages and consider use of the TCE accordingly. Conflict of Interest: None declared.

STOMACH AND SMALL INTESTINE: ENDOSCOPY: SMALL BOWEL ENTEROSCOPY P136: ENTEROSCOPY IN DIAGNOSIS AND MINIMALY INVASIVE TREATMENT OF PATIENTS WITH THE PEUTZ-JEGHERS SYNDROME Ekaterina Ivanova1, Denis Seleznev1, Mikhail Timofeev2, Oleg Yudin1, Natalia Marenich3, Evgeny Fedorov2 1

P135: FUJINON THIN CALIBER ENDOSCOPE IN DAILY PRACTICE: THERAPEUTIC APPLICATIONS BASED ON THE REVIEW OF 600 CASES Roxana Sadagurschi, Lucian Negreanu Emergency University Hospital Bucharest, Bucharest, Romania

AIMS: Thin caliber endoscopes (TCEs) are versatile and useful in various conditions. However, only limited data exist on the actual daily clinical use of such scopes especially in therapeutic purposes. The aim of our study was to present our experience using the Fujinon TCE.

METHODS: We performed a six months retrospective analysis of our database of procedures with 6oo endoscopies in 567 patients. All procedures were carried out in the University Hospital Bucharest, between August 2015 and March 2016. In these procedures, the Fujinon (Tokyo, Japan) EG-530 endscope

Medical Center ‘Klinika K+31’, 2Moscow University Hospital No 31, and 3Morozovskaya Children’s Hospital, Moscow, Russia

AIMS: Intussusception and bleeding are the main complications of Peutz-Jeghers syndrome (PJS), often requiring surgery. We evaluated the efficiency of balloon-assisted (BAE) therapeutic enteroscopy in patients with PJS. METHODS: From I.2007 to VIII.2016 we examined 19 patients with PJS, including two 8-year old twins (m-11, f-8, ranged 843 years, mean age 27 10.1 years). The duration of disease in 17 (89.5%) patients was more than 8 years, while only in 2 (10.5%) less than a year. Iron-deficiency anaemia had 6 (31.6%) patients; laparotomy for intussusception underwent 14 (73.7%) patients, among them 6 (42.9%) from 3 to 9 laparotomies. Videocapsule endoscopy was carried out in 14 (73.7%) patients. We performed 48 therapeutic BAE in 15 (78.9%) patients: 32 (66.7%) perorally and 16 (33.3%) transanally.

RESULTS: Hamartomas were spread along the entire small bowel in 9 (47.3%) patients; located in jejunum in 8 (42.1%); in


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 ileum in 1 (5.3%); in colon in 1 (5.3%) patient. The polyp´s size ranged from 5 to 65–70 mm (mean 21.7 14.6 mm), while hamartomas larger than 30 mm were revealed in 9 (60.0%) patients. In course of BAE we removed 234 polyps, including 197 (84.2%) in jejunum and ileum (macroscopically 128 (65.0%) were pedunculated and 69 (35.0%) - sessile), 17 (7.3%) in duodenum, 19 (8.1%) in colon. In one enteroscopy session we resected from 1 to 23 (mean 5 4.4) polyps. Endoscopic resection was performed by snare polypectomy for 170 (72.6%) polyps, EMR for 55 (23.5%), EMR with prior endo-loop application for 3 (1.3%), EMR with prior clipping of the stalk for 6 (2.6%) polyps. Intraoperative bleeding occurred during endoscopic removal in 3 (20.0%) patients; postoperative bleeding was observed in 3 (20.0%) patients; all bleedings were stopped endoscopically.

CONCLUSIONS: Almost in half (47.3%) of the patients hamartomas were located throughout the small intestine, requiring both peroral and transanal therapeutic BAE; polyps of large size had 60.0% of patients from therapeutic group, where BAE allowed to remove all hamartomas endoscopically, thus preventing further complications of PJS and surgery. Conflict of Interest: None declared.

P137: MICROVILLI ATROPHY IN THE TERMINAL ILEUM IS A SPECIFIC ENDOSCOPIC FINDING CORRELATED WITH ACUTE GVHD AND POOR PROGNOSIS AFTER ALLO-HEMATOPOIETIC STEM CELL TRANSPLANTATIONΔ Yuusaku Sugihara1, Sakiko Hiraoka1, Nobuharu Fujii2, Shiho Takashima1, Daisuke Takei3, Toshihiro Inokuchi1, Masahiro Takahara1, Kenji Kuwaki4, Keita Harada3, Takehiro Tanaka5, Hiroyuki Okada1 Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences 1Department of Gastroenterology and Hepatology, Okayama, Japan, 2 Department of Hematology and Oncology, Okayama, Japan, 3Department of Endoscopy, Okayama, Japan, 4Center for Innovative Clinical Medicine, Okayama, Japan and 5 Department of Diagnostic Pathology, Okayama, Japan

AIMS: Graft-vs-host disease (GVHD) is a common complication of allo-hematopoietic stem cell transplantation (allo-HSCT). This study evaluated whether terminal ileum imaging predicted acute GVHD severity after allo-HSCT. METHODS: Consecutive patients who underwent allo-HSCT were referred to the Okayama University Graduate School of Medicine between May 2008 and September 2015, and those diagnosed with acute GVHD by pathological diagnosis were included in this retrospective study.

RESULTS: Fifty-one of 261 patients who underwent colonoscopy were suspected to have acute intestinal GVHD. Six patients were excluded because their colonoscopy had not been completed (n = 6). On univariate analysis, the factors of


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microvilli atrophy, erythema in the terminal ileum, and erosion in the right hemi-colon were significantly related with acute GVHD. Using these factors, a multivariate conditional logistic regression with stepwise variable selection was performed, and microvilli atrophy in the terminal ileum remained statistically significant (odds ratio [OR], 4.69; 95% confidence interval [CI], 1.069–20.597, P = 0.041). Patients were classified into three groups based on colonoscopy findings for the terminal ileum: group S, GVHD with severe microvilli atrophy in the terminal ileum; group M, GVHD with mild microvilli atrophy; and group N, absence of microvilli atrophy. Compared with patients in groups M and N, those in group S had significant clinical GVHD at diagnosis (P = 0.033). In group S, 3 of 4, compared with 5 of 13 patients in groups M and N, required the addition of second-line agents (P = 0.024). The mortality was 0.44 per person-year in group S, 0.53 per person-year in group M, and 1.05 per person-year in group N after allo-HSCT.

CONCLUSIONS: This study showed that severe atrophy of the terminal ileum predicts severe clinical GVHD that is likely to be refractory to steroid treatment. Thus, the severity of terminal ileum atrophy may serve as a tool in predicting clinically severe GVHD. Conflict of Interest: None declared.

P138: A DECADE WITH CAPSULE AND BALLOONASSISTED ENTEROSCOPY FOR DIAGNOSTICS AND TREATMENT OF SMALL BOWEL DISEASES: THE “MINE” WAS EXAMINED, EXPLORATIONS ARE CONTINUING♦ Ekaterina Ivanova1,2, Evgeny Fedorov1,2, Denis Seleznev1,2, Ekaterina Tikhomirova1 1

Pirogov Russian National Research Medical University, and Medical Center ‘К+31’, Endoscopy, Moscow, Russia

2

AIMS: Video capsule endoscopy (VCE) and balloon-assisted enteroscopy (BAE) are the recent modalities which allow not only to evaluate the small bowel diseases, but also to choose the most accurate therapy. The aim of the study is to evaluate the clinical utility of VCE and BAE in daily practice. METHODS: From 14.02.2007 to 11.07.2016 enteroscopy was performed in 500 patients (m–265, f–235, mean age 48.1 16.9 years, range 18–84), including 24 patients with long afferent loop for performing therapeutic ERCP. The indications for intestine evaluation in 476 patients included: suspected small bowel bleeding - in 177 (37.1%), intestinal tumor - in 89 (18.7%), inflammatory bowel disease - in 115 (24.1%), others (cancerophobia, helminthosis, etc.) - in 95 (19.9%) patients. We performed 373 VCE in 353 (74.1%) patients and 375 BAE in 256 (53.7%) patients, including 210 (56.0%) BAE after VCE. The combined use of VCE and BAE was conducted in 138 (39.1%) of 353 patients.


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RESULTS: Using VCE and BAE intestine abnormalities were revealed in 277 (58.2%) patients: vessel malformation in 68 (24.5%), tumors in 79 (28.5%), enteropathy - in 100 (36.1%), other disorders - in 30 (10.8%) patients; no abnormalities were revealed in 196 (41.1%) patients. Endoscopic treatment was performed in 65 (23.5%) patients, including removal of multiple polyps in 14 (21.5%) with Peutz-Jeghers syndrome and endoscopic hemostasis in 28 (43.1%). Surgical treatment was performed in 46 (16.6%) patients, mainly for small bowel tumors - 29 (63.0%). Adverse events, related to VCE was capsule retention in 6 (1.7%) patients; related to BAE in 7 pts (1.9%): bleeding after biopsy and polypectomy (3), perforation (2) and gastric cardia tears (2). CONCLUSIONS: In just 10 years VCE and BAE have significantly changed our understanding of diseases of the small intestine and provided essential benefits in proper, accurate diagnosis as well as possibilities of endoscopic treatment. And this is not the last word. Conflict of Interest: None declared.

P139: ASSESSMENT OF SMALL BOWEL CAPSULE ENDOSCOPY AND APC GENE MUTATION IN FAMILIAL ADENOMATOUS POLYPOSIS Tomoyuki Kawaguchi, Naoki Muguruma, Koichi Okamoto, Kumiko Tanaka, Satoshi Teramae, Yasuhiro Mitsui, Yoshifumi Takaoka, Tatsunao Sueuchi, Takahiro Goji, Shinji Kitamura, Masako Kimura, Tetsuo Kimura, Hiroshi Miyamoto, Tetsuji Takayama Institute of Biomedical Sciences, Tokushima University Graduate School, Department of Gastroenterology and Oncology, Tokushima City, Japan

AIMS: Familial adenomatous polyposis (FAP) is a hereditary polyposis syndrome predisposed to colorectum. The frequency and the clinical significance of the small intestinal polyps in FAP patients are still unknown. In this study, we investigated the small intestine in patients with FAP using video capsule endoscopy (VCE) and double balloon enteroscopy (DBE). We also analyzed germline mutation of the APC gene to evaluate the correlation between the number of polyps and APC mutation.

METHODS: A total of 21 patients with FAP were enrolled (age: 16–66, mean: 48.2, male:female=6:15) and VCE or DBE were performed. Esophagogastroduodenoscopy was also performed and Spigelman classification was applied to assessment of duodenal polyps. Genomic DNA was extracted from peripheral lymphocyte and a full sequence of exon 1 - 15 of APC gene was performed.

RESULTS: The relationship between Spigelman classification and the number of small bowel polyps was as follows : stage 0, 1.22 3.31; stage I, 5.0; stage II, 18.6 19.6; stage III, 37.3 33.8; stage IV, 36.5 51.6; stage V, more than 120. The germline mutations of APC gene were detected in 14 of 21

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 cases (66.7%). APC mutations were detected in exon 4, 6, 11, 14, 15, and complete deletion of APC gene was found in one case that had small bowel polyps more than 120 and adenoma with severe dysplasia sized 20 mm in the jejunum. The number of polyps in patients with APC exon 11 mutations was significantly higher than those in patients with the other APC mutations.

CONCLUSIONS: Our data suggest that endoscopic surveillance for the small bowel using VCE and DBE is important in FAP, even in the cases with early stage of Spigelman classification. Our results also suggest a genotype-phenotype correlation between polyp development in the small intestine and APC mutation. Conflict of Interest: None declared.

P140: CLINICAL IMPACT OF THE FIRST BIOPSY BY USING DOUBLE-BALLOON ENTEROSCOPY IN SMALL BOWEL DISEASE Hwa-Sun Park, Seong Ran Jeon, Hyun Gun Kim, Tae Hee Lee, Jun-Hyung Cho, Junseok Park, Joon Seong Lee, Jin-Oh Kim Soonchunhyang University, Digestive Reserch, Digestive Disease Center, Division of Gastroenterology, College of Medicine, Seoul, Korea

AIMS: Non-surgical pathologic diagnosis of small bowel disease is desirable for defining subsequent treatment and prognosis. However, diagnostic yield of biopsy by using double-balloon enteroscopy (DBE) in patients with small bowel disease is a limited data available. Therefore, our study aimed to evaluate the diagnostic yield of enteroscopic biopsies and especially clinical significance of the first biopsy. METHODS: Of total 211 DBE procedures, 74 DBEs (67 patients; mean age 43.2 17.0 years; male 63.5%) performed enteroscopic biopsies were analyzed retrospectively. Histological findings obtained by enteroscopic biopsies were compared with the final diagnosis assessed by surgery or by using a combination of clinical course and radiologic features. Diagnostic yield based on the first biopsy and including over the second biopsy were assessed respectively.

RESULTS: Obscure gastrointestinal bleeding (35.1%) was the most common indication for DBE was 92%. Crohn’s disease (37.8%) was the most common final diagnosis, followed by enteritis/enteropathy (24.3%), adenocarcinoma (8.1%), tuberculous enteritis (5.4%). The mean number of biopsy 3.5 2.3 (range 1–12). Overall diagnostic yield of enteroscopic biopsy was 54.1% (40/74). In subgroup analysis, diagnostic yield of tumor and inflammatory mucosal lesions were 81.1% (9/11) and 51.9% (28/54), respectively (P = 0.06). Diagnostic yield of the first biopsy was 50% (37/74) and second additional biopsy slightly increased the yield to 54.1% (40/74). Up to 95% of cases was diagnosed by the first biopsy (P < 0.001). A correct diagnosis of enteroscopic biopsy was not related age,


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 abdominal operation history, the number of biopsy, the presence of multiple lesions and site of lesions.

CONCLUSIONS: The diagnostic yield of enteroscopic biopsy in patients with small bowel disease was 54.1%. Because the majority of cases diagnosed with biopsy were confirmed as the first biopsy, the first biopsy will have to be done carefully. Conflict of Interest: None declared.

P141V: HAEMOSTASIS IN PATIENTS WITH POST SURGICAL ALTERED ANATOMY USING SINGLE BALLOON ENTEROSCOPE Hrushikesh Chaudhari, Mohan Ramchandani, Manu Tandan, P. Manohar Reddy, D. Nageshwar Reddy


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CONCLUSIONS: SBE is useful and safe in controlling bleeding due to various etiologies in patients with surgically altered anatomy. Conflict of Interest: None declared.

P142: ROLE OF NARROW BAND IMAGING IN DIAGNOSING TC-99M SCINTIGRAPHY NEGATIVE MECKEL’S DIVERTICULUM IN ADULT PATIENTS WITH OBSCURE GI BLEEDING USING SINGLE BALLOON ENTEROSCOPE Hrushikesh Chaudhari, Manu Tandan, Mohan Ramchandani, P. Manohar Reddy, D. Nageshwar Reddy Asian Institute of Gastroenterology, Hyderabad, India

Asian Institute of Gastroenterology, Hyderabad, India

AIMS: To study the efficacy and role of single balloon enteroscopy (SBE) in achieving haemostasis due to various etiologies in patients with surgically altered anatomy.

METHODS: This is a retrospective case study. Patient demographics, clinical data, procedural details and complications were obtained. Two patients with surgically altered anatomy underwent SBE for GI bleeding at Asian Institute of Gastroenterology, Hyderabad, India.

RESULTS: CASE 1: 38 years old male, case of chronic pancreatitis, post Gastrojejunostomy with Hepaticojejunostomy for inflammatory mass in pancreatic head, presented with recurrent melena since 1 month. His laboratory evaluation showed low haemoglobin (6.5 gm/dL). Endoscopy and colonoscopy were not contributory. CT scan of abdomen revealed bulky head of pancreas with portal vein thrombosis and collaterals. Capsule endoscopy revealed blood clots in jejunum. Antegrade SBE revealed hepaticojejunostomy anatomotic site varices with ooze. A total of 5 mL of glue (N-butyl-2cyanoacrylate) was injected into varices using 25 gauge needle. Glue injection was done in two sessions on two consecutive days. Follow up ultrasound abdomen with color doppler showed echogenic glue cast and obliteration of collaterals at hepaticojejunostomy site. CASE 2: 70 years old male, case of Chronic pancreatitis, Post Pancreaticojejunostomy for carcinoma pancreas, presented with intermittent melena for 2 Months. He also had history of Nonsteroidal anti-inflammatory drug intake. His laboratory evaluation showed severe anaemia (Hb 5.7 gm/dL). Endoscopy, colonoscopy and capsule endoscopy were normal. 99mTc RBC scintigraphy localized bleeding in mid abdomen. During Antegrade enteroscopy, pancreatico-jejunostomy site revealed ulcer with ooze. Argon plasma coagulation of actively oozing ulcer base was done. In both patients further hospital stay was uneventful. There were no procedure related complications observed. There was no further episode of bleed or drop in hemoglobin occurred over 18 months of follow up.

AIMS: To evaluate the role of single balloon enteroscopy (SBE) in diagnosing Meckel’s diverticulum (MD) and role of Narrow band imaging (NBI) in identification of ectopic mucosa. METHODS: From December 2010 to December 2015, SBE was performed in patients with obscure GI bleeding and a diagnosis of MD was made preoperatively in 5 patients. Obscure GI bleeding is defined as bleeding from the GI tract that persists or recurs without an obvious cause after endoscopic (upper GI endoscopy and colonoscopy) and imaging studies.

RESULTS: In five patients (4 male, 1 female; mean age 25.4 years, range 11–35 years) MD was detected in distal ileum during enteroscopy. The mean hemoglobin on admission was 6.78 0.90 g/dL. In all these five patients, preprocedural Tc-99 m pertechnetate scintigraphy failed to diagnose MD. During SBE examination, intubation of MD was successful in all five cases. NBI identified ectopic gastric type of mucosa in all patients showing pathognomic features like small regular pit pattern, epithelial crest and narrow grooves. No procedure-related complications occurred. All patients underwent surgical resection. The mean distance from the diverticulum to the ileocecal valve was 71 cm (range 55–110 cm). Diverticulum length ranged from 2.5 cm to 5.0 cm, and diameter ranged from 2 cm to 3.5 cm. Histological assessment confirmed the presence of ectopic gastric mucosa. SBE along with NBI was the only nonsurgical procedure that provided accurate preoperative diagnosis. The mean hemoglobin level 6 months after surgery was 12.94 g/dL. The mean follow-up was 16 months (range 6–24 months). On follow-up, there was no GI bleed in all 5 patients. CONCLUSIONS: Considering the low sensitivity and limitations of Tc-99 m scintigraphy, single-balloon enteroscopy with Narrow band imaging might be the modality of choice in patients with obscure GI bleed with a suspected diagnosis of Meckel’s diverticulum. Conflict of Interest: None declared.


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P143V: ENDOSCOPIC CLOSURE OF HEPATICOJEJUNOSTOMY ANASTOMOTIC SITE PERFORATION USING METALLIC CLIP AFTER SINGLE BALLOON ENTEROSCOPY (SBE) ASSISTED THERAPEUTIC ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) Hrushikesh Chaudhari, Mohan Ramchandani, Manu Tandan, D. Nageshwar Reddy Asian Institute of Gastroenterology, Hyderabad, India

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 CONCLUSIONS: Endoscopic closure of Hepatico-Jejunostomy anastomotic perforation using clip after SBE Assisted Therapeutic ERCP is safe and efficacious. Conflict of Interest: None declared.

P144: SINGLE BALLOON ENTEROSCOPY (SBE) ASSISTED THERAPEUTIC ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) IN PATIENTS WITH SURGICALLY ALTERED ANATOMY

AIMS: Role of clip in anastomotic perforation closure in SBE assisted ERCP.

Hrushikesh Chaudhari, Mohan Ramchandani, Manu Tandan, P. Manohar Reddy, D. Nageshwar Reddy

METHODS: A 29 year old female presented with recurrent


cholangitis since 2 years. Past history revealed status post Whippel’s pancreaticoduodenectomy for serous cystadenoma of pancreas 7 years back. Laboratory data revealed total bilirubin 4.9 mg/dL, Alkaline phosphatase 961 IU/L, aspartate transaminase 401 IU/L, alanine transaminase 559 IU/L, white cell count 18000 109/L. Abdominal ultrasound showed dilated intrahepatic biliary radicals (IHBR). Magnetic resonance cholangiopancreatography revealed dilated IHBR and stricture at hepatico-jejunostomy anastomotic site. She underwent SBE assisted ERCP. The SBE system consists of a enteroscope (SIF-Q180; Olympus Medical Systems, Japan), overtube with a balloon (ST-SB1; Olympus), and a balloon controller (XMAJ-1725; Olympus). The enteroscope has a working length of 200 cm and working channel diameter of 2.8 mm. Through Roux limb afferent limb was intubated which revealed pin point stricture at Hepatico-Jejunostomy anastomotic stricture. Stricture was cannulated using Soehendra Biliary Dilation Catheter (Cook Medical Inc.). Cholangiogram showed tight stricture at with dilated IHBR. Stricture dilatation was performed using 12 mm diameter balloon catheter (Quantum TTC Biliary Balloon Dilators; Cook Medical, Inc. USA) over the guide-wire. Bilioenteric anastomosis was widened by endoscopic stricturoplasty with needle knife (Zimmon needle knife papillotome, Cook Medical Inc.). Subsequently to prevent recurrence of stricture two 7Fr double pig tail plastic stents (Cook Medical, Inc. USA) were put across the stricture. During stent placement, perforation showing peritoneum near bilioenteric anastomosis was noticed. Subsequently perforation was closed with metallic clip (ResolutionTM Clip, Boston Scientific Inc. USA). Both the edges were secured closely by clip.

AIMS: The aim of this study was to evaluate the usefulness of single-balloon enteroscopy (SBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy (B-II) or Roux-en-Y anastomosis (R-Y). METHODS: 22 SBE procedures were performed in 21 patients with 6 B-II and 15 patients with R-Y at Asian Institute of Gastroenterology, Hyderabad, India. This is a retrospective cohort study.

RESULTS: In all cases but one (95.24 %, 20/21), the papilla or anastomotic site could be reached with the SBE. The rate for B-II and R-Y were 100 % (6/6), and 93.3 % (14/15), respectively. The mean time required to reach the papilla or anastomotic site was 54.1 min (range 28–90 min). In cases of R-Y, the mean time required to reach the papilla or anastomotic site was 58.6 min (range, 30–90 min). The overall success rate of the therapeutic ERCP on the first session was 80.9 % (17/21). In patients with an intact papilla, the success rate on the first session was 71.4 % (5/7). With regard to the type of surgery, the success rate of the procedure in patients with B-II and R-Y was 83.3 % (5/6) and 80 % (12/15), respectively. The mean procedural time for --- successful groups on the first session was 51.1 min (range, 28–90 min). One patient also underwent extracorporeal shock wave lithotripsy for large calculi at bilioenteric anastomosis. Three patient had bowel perforation out of which one underwent endoscopic closure of the perforation using clip and rest two were managed surgically. CONCLUSIONS: SBE-assisted ERCP using an overtubeassisted technique appears to be promising for performing therapeutic ERCP in patients with B-II or R-Y. Conflict of Interest: None declared.

RESULTS: CT abdomen revealed few air pockets around hepatico-jejunostomy without any fluid collection. Subsequently on 3rd day liver functions normalized and patient was discharged. On two month follow up, patient was asymptomatic with normal abdominal ultrasonography.




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STOMACH AND SMALL INTESTINE: ENDOSCOPY: VARICES/PORTAL HYPERTENSION

P146: MODERN ENDOSCOPY IN TREATMENT OF NON-ULCERATIVE ESOPHAGEAL-GASTRIC BLEEDING

P145: NONINVASIVE PREDICTION OF THE OESOPHAGEAL VARICES GRADE (SIZE) IN SUDANESE PATIENTS WITH PERIPORTAL FIBROSIS

Avicenna Tajik State Medical University, Department of Surgical Diseases No 1, Dushanbe, Tajikistan

Mohammed Mohammed1, Amin Abbas2, Mohammed Gadour3, Elkhawad Osman4

AIMS: Improving the results of complex conservative and endoscopic treatment of non-ulcerative esophageal-gastric bleeding.

Nile Valley University, Medicine, Atbara, 2Ibnsina Specialized Hospital, Medicine, Khartoum, 3Omdurman Islamic University, Medicine, Omdurman, and 4Ibnsina Specialized Hospital, Radiology, Khartoum, Sudan

1

AIMS: To identify hematological (platelet count), and ultrasonographic predictors of oesophageal varices. METHODS: Cross-sectional, analytical prospective hospital based study. Place and duration of Study: At Ibn Sina Hospital and National Center of GIT Bleeding, in the period from November 2011 to August 2012. One hundred patients were included in the study; all had schistosomiasis as evident by ultrasonography.

RESULTS: Mean age of study was 43.9 14 yeas, male affected more than female, male to female ratio was 3 : 1, common age group 41–60 years, and those whom from center of Sudan, mainly Algezera represent 79%, large oesophageal varices is found in 81 (81.0%) patients (LOV: SOV 4:1). Schistosoma Mansoni sonographic score (SMS), which account for the degree of periportal fibrosis and portal vein dilation were calculated for all patients. High significant correlation existed between high SMS score and large oesophageal varices (P = 0.0001). SMS at the cut of point 2 was high sensitive (95.1%) and specificity (57.9%) in detecting (LOV). Also platelet count show high correlation with the grade of oesophageal varices (P = 0.0259), platelets count at the cut of point 121 mm/l has sensitivity (42%) and specificity of (73.7%). Spleen size by ultrasound measuring 14.5 cm has high sensitivity in detecting LOV (95.1%) and positive predictive value (83%). CONCLUSIONS: These result highlight the emerging new role of ultrasound in predict the oesophageal varices grade hence the application of endoscopy if available at all endemic area may be restricted to patients at risk of having large oesophageal varices as determined by ultrasonograhy and platelets count. Conflict of Interest: None declared.

Farukh Makhmadov

METHODS: We have our experience in the diagnosis and treatment of 134 patients with esophageal-gastric bleeding. At the same time, 93 (69.4%) patients the cause of bleeding is portal hypertension due to cirrhosis of the liver. In 41 (30.6%) syndrome Mallory-Weiss. The age of patients ranged from 24 to 78 years.

RESULTS: In 19 patients had jaundice, an enlarged liver (n = 8), biochemical disorders in the blood parameters (n = 20). An important method of conservative treatment of esophageal-gastric bleeding in the 28 observations is transgastralnoe keeping Blackmore probe with sequential inflation of gastric balloon. In order to reduce portal pressure and intragastric five observations pituitrin administered 20 Units. intravenous infusion over 20 minutes, every 30 minutes, even 5–10 Unit. intravenously. Also, to reduce the portal pressure at 27 observations used effectively prolonged imperative nitrate solution at 10 mg per 400 mL of Ringer´s solution. Gemokoaguailary therapy started with fresh frozen plasma, 10% in 200–300 mL of albumin solution. An effective method to prevent disseminated intravascular coagulation is a designated krioplazmy in combination with protease inhibitors. To strengthen the hemostasis and improve microcirculation in 94 observations administered sodium etamzilat. Endoscopic hemostasis techniques applied in 41 cases. In the 32 cases was performed endoscopic hemostasis at bleeding from varicose veins of the esophagus and stomach, at 9 in the syndrome of Mallory-Weiss. As the sclerosing agent in 22 patients was used 70% ethanol, and 19 used diathermocoagulation observations. CONCLUSIONS: When non-ulcerative bleeding from the upper digestive tract the most effective method of hemostasis is conservative and endoscopic treatment, after which the mortality rate was 9.8%. Conflict of Interest: None declared.

P147: PORTAL HYPERTENSIVE POLYPS PREVALENCE AND RISK FACTOR A PROSPECTIVE STUDY Pinakin Patel, Deepak Amarapurkar Bombay Hospital and Medical Research Centre, Gastroenterology, Mumbai, India


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AIMS: Apart from oesophago gastric varices, portal hypertensive gastropathy (PHG), gastric antral vascular ectasia (GAVE) and portal hypertensive polyps (PHP) are commonly described findings in upper GI endoscopy in patients with portal hypertension (PH). We planned this prospective study to estimate prevalence and risk factors for PHP. METHODS: 350 consecutive patients of PH were evaluated prospectively for upper gastro intestinal mucosal changes over a period of 1 year. Diagnosis of PHG, GAVE and PHP was done on endoscopic findings correlated with histology whenever required.

RESULTS: Out of total 350 patients, the prevalence of gastrodeuodenal PHP was 10.5%, oesophageal varices (large 51.1%, small 43.4%), gastric varices 16%, PHG 72.8%, GAVE 9.1% and gastroduodenal ulcers 7.1%. All the patients were evaluated further for the development of PHP considering their previous history of oesophageal variceal band ligation (EVL), treatment with or without proton pump inhibitors, etiology of cirrhosis and size of oesophageal varices over 1 year. Out of the 350 patients, 185 had a past history of EVL and 165 had no past history of EVL. The development of PHP was significantly (P < 0.05) associated with previous history of EVL, but independent of other variables. Out of 350 patients, 23 patients underwent successful EVL, of which 18 had PHG (severe-5, mild13) before therapy. After successful EVL18 patients had PHG (severe-12, mild-6), but severity of PHG was significantly (P < 0.05) increased. CONCLUSIONS: The development of gastrodeuodenal PHP was independent to size of oesophageal varies, with treatment of proton pump inhibitors and etiology of cirrhosis, but significantly associated with previous history of oesophageal variceal band ligation. Apart from oesophago gastric varices, PHG, GAVE and gastrodeuodenal ulcers are important cause of bleeding & chronic iron deficiency anaemia of unexplained reasons in patients with PH. Severity of PHG was significantly increased following successful either band ligation or sclerotherapy. Conflict of Interest: None declared.

P148: MORTALITY PREDICTORS IN ACLF PATIENTS Rajesh Gupta, Sujay Kulkarni, P. N. Rao, R. G. Gupta, M. Sharma, D. Nageshwar Reddy Asian Institute of Gastroenterology, Medical Gastroenterology, Hyderabad, India

AIMS: The study was designed to find the in-hospital predictors of mortality of acute on chronic liver failure (ACLF) and also find the clinical and biochemical profile of Indian patients presenting as ACLF. METHODS: Patients who were admitted to the medical intensive care unit of a teritiary care hospital fulfilling the definition of ACLF based on the Asia-Pacific Association of Study of Liver Disease (APASL) consensus were included in the study.

Data was prospectively recorded and the various scoring systems and individual clinical and laboratory parameters were assessed to identify predictors of 28 days mortality.

RESULTS: Out of 240 patients screened for ACLF, 64 patients were finally analyzed in the study. The median age was 44 years and 53% were males. Alcohol was the primary cause of cirrhosis in 60.93% cases. Infections and active alcoholism was the main precipitating acute insult in 43% and 37% patients respectively.28% patients had history of ingestion of hepato-toxic drugs as the acute insult. More than one acute insult was seen in 37.5% patients and type II hepatic injury was the most common type. 28 days in hospital mortality was 43.75% and was highest in patients with sepsis (67.8%). Presence of hepato-renal syndrome and need for ventilation was associated with poor outcome. APACHE II and shock could significantly predict mortality with odds ratio of 3.18 and 9.14 respectively. The highest mortality was seen with cerebral and lung involvement as organ failure and mortality increased as the number of organ failure worsened. CLIF-SOFA and APACHE II scores having area under curve >0/8 had higher ability to predict mortality. CONCLUSIONS: ACLF carries high short term mortality and early intervention in form of liver transplantation should be considered in patients who shows high risk of mortality based on predictors and scoring systems. Conflict of Interest: None declared.

P149: RENTABILITY OF UPPER ENDOSCOPY FOR THE DIAGNOSIS AND THE MANAGEMENT OF PORTAL HYPERTENSION BLEEDING riam Sabbah1,2, Asma Ouakaa1,2, Norsaf Bibani1,2, Dorra Me Trad1,2, Dalila Gargouri1,2, Nawel Bellil1,2, Ala Ouni1,2, Hela Elloumi1,2, Jamel Kharrat1,2 1


AIMS: Upper endoscopy has an interest in both diagnostic, therapeutic and prognostic for the treatment of portal hypertension bleeding. The aim of our study was to determine the diagnostic and therapeutic contribution of upper endoscopy in the management of portal hypertension bleeding in our experience. METHODS: All consecutive patients who underwent upper endoscopy for bleeding during 2015 were included. Following parameters were included: age, gender, time of endoscopy, endoscopic lesions, type of endoscopic hemostasis technique and outcome.

RESULTS: Among the 110 patients with bleeding, 43 had portal hypertension (39%). The etiology of portal hypertension was dominated by cirrhosis (46%). Upper endoscopy was performed at the twelfth hour, in 65% of cases and without sedation in 54%. In three cases (7%) upper endoscopy was not contributive due to the abundance of blood in the stomach,


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 requiring to repeat the exam next day. Endoscopy objectified esophageal varices in 80% of patients, most were grade III (72%), gastric varices in 14 patients (32%) type GOV 1 (n = 6) GOV 2 (n = 4), IGV 1 (n = 4), hypertensive gastropathy in 32% of cases and vascular ectasia antrum in two patients. Associated lesions found were gastro duodenal ulcer in two patients and esophagitis in two others. Endoscopic ligation was performed in most cases (90%). and glue injection in 10%. Patients with antral vascular ectasia or hypertensive gastropathy bleeding were stabilized on medication (vasoactive treatment). A success of endoscopic treatment was observed in 100% of patients. Regarding complications, a rebleeding due to eschar was noted in 6 cases, and stenosis was observed in one case.

CONCLUSIONS: In our cohort, upper endoscopy performed during portal hypertension bleeding had an excellent diagnosis rentability of 93%. The combined endoscopic hemostasis vasoactive treatment helped stabilize patients in 100% of cases. Conflict of Interest: None declared.

P150: PREVELANCE OF H. PYLORI INFECTION IN CIRRHOTIC PATIENTS WITH PORTAL HYPERTENSIVE GASTROPATHY Ahmed Mohammed El Nakib Mansoura University, Mansoura, Egypt

AIMS: To investigate the prevalence of H. pylori infection and its association with PHG in patients with liver cirrhosis.

METHODS: Out of 200 patients underwent upper gastrointestinal endoscopy for early screening of varices 80 cirrhotic patients with PHG (cases) and 80 cirrhotic patients without PHG (controls) underwent multiple gastric biopsies for histopathological examination for the presence or abscence of H. pylori infection.

RESULTS: The presence of H. pylori was observed in 44 (55%) cirrhotic patients with PHG (cases) compared to 21 (26.2%) cirrhotic patients without PHG (controls). The risk estimate showed a significant association between H. pylori and PHG in cirrhotic patients (P < 0.001). Out of the 44 patients with PHG and H. pylori infection, 23 had severe PHG and 15 had mild PHG while 6 patients had severe PHG. In patients with negative H. pylori infection 34 patients had mild PHG. The difference was statistically significant (P < 0.001). Of the 80 patients with PHG, 32 had severe PHG and of these 26 (81%) were in Child C compared to 6 (18.75%) in Child B.

CONCLUSIONS: H. pylori needs to be eradicated in cirrhotic patients with PHG as there is significant association between H. pylori infection and PHG in cirrhotic patients which is also related to severity of PHG. Conflict of Interest: None declared.


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P151: CLINICAL PROFILE, EFFICACY AND OUTCOME OF ENDOSCOPIC MANAGEMENT OF DUODENAL VARICEAL BLEEDING WITH CYANOACRYLATE GLUE INJECTION Hrushikesh Chaudhari, Manu Tandan, Mohan Ramchandani, Sundeep Lakhtakia, Rajesh Gupta, D. Nageshwar Reddy Asian Institute of Gastroenterology, Hyderabad, India

AIMS: Duodenal varices (DV) are the second most common cause of ectopic variceal bleeding. Limited data is available regarding the management of DV. This study aimed to evaluate clinical presentation, etiological spectrum and management of DV using N-butyl-2-cyanoacrylate injection. METHODS: All patients admitted with diagnosis of bleeding duodenal varices, between January 2010 to August 2016, were analyzed prospectively. The clinical data, relevant investigations, treatment modalities and outcome were reviewed.

RESULTS: 25 patients (Twenty males; mean age - 37.28 years) with DV were included. Etiology for DV was extra-hepatic portal venous obstruction (EHPVO) in 76% (19/25), chronic liver disease in 20% (5/25) and non-cirrhotic portal fibrosis in 4% (1/25) patients. Chronic pancreatitis was present in 36.8 % (7/19) patients of EHPVO. Seventeen patients presented with hematemesis. Nineteen patients were diagnosed on first endoscopy. Most common location for DV was second part of duodenum. Esophageal and fundal varices were present in 76% (19/25) and 16% (4/25) patients respectively. Endoscopic ultrasound was performed in six patients, out of which one patient underwent EUS guided Nbutyl-2-cyanoacrylate injection. Endoscopic hemostasis with cyanoacrylate injection was performed in all patients. Mean volume of cyanoacrylate injected was 2.4 mL (range, 1–4 mL). Mean sessions required were 1.44 (range 1–3). 20% (5/25) patients had rebleed after endotherapy. Out of these five patients, two patients underwent surgery, coil embolization in one and repeat cyanoacrylate injection in two patients. There has been no recurrence of bleed due to DV over the mean follow-up 22.6 months (range, 6–44 months). CONCLUSIONS: EHPVO is most common cause of bleeding from duodenal varices. Endoscopic treatment with N-butyl-2cyanoacrylate injection is effective and safe for bleeding duodenal varices. Conflict of Interest: None declared.

P152: ADEQUACY OF VARICEAL GLUE INJECTION USING WATER SOLUBLE CONTRAST FOLLOWING ENBUCRYLATION -- AN EXPERIMENTAL STUDY Raiza Geires Bondoc, Evan Ong Metropolitan Medical Center, Manila, Philippines


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AIMS: Bleeding from gastric varices can be challenging because of its high mortality. Endoscopic therapy with histoacryl can control acute bleeding but recurrence may occur if obliteration is not achieved, and endoscopic vision could be troublesome in the case of a massive hemorrhage. In instances where pure glue is utilized, and in the absence of an endoscopic ultrasound, post injection imaging evaluation would prove to be a challenge. The objective of this study is to assess the efficacy of a water-soluble contrast in confirming location and evaluating completeness of variceal obliteration after pure glue injection.

RESULTS: A total of 6 studies were included in this metaanalysis. Analysis of these studies found that heparin bridge therapy was associated with an increased risk of post gastric ESD bleeding compared to no heparin bridge therapy as controls (summary RR = 7.85, 95% CI =4.81–12.80: P heterogeneity= 0.004, I2 =71.3 %: n = 6 studies). The positive association increased when we limited the controls to no antithrombotic user (summary RR = 8.71, 95% CI =4.26–17.78: P heterogeneity 2 g/dL, 2) anemia required transfusion, 3) requiring additional procedure such as endoscopic hemostasis. Minor bleeding was defined as having the bleeding symptom without above mentioned criteria.

possible causes of this complication. Early diagnosis can avoid fetal outcomes. Conflict of Interest: None declared.

RESULTS: The number of patients who received EMR or ESD was 594. Of 594, 57 were prescribed anti-thrombotic agents. The rate of patients prescribed warfarin of Group H was significantly higher than that of Group N (96.7 % vs 37.0 %; P < 0.001). The ratio of EMR /ESD was not significantly different between two groups (Group H 76.6% vs Group N 61.5%; P = 0.22). The adverse event on arterial thromboembolism did not occurred in both groups. Group H had much major bleeding events as compared with Group N (26.6 % vs 3.7%; P = 0.018), on the other hands, rate of minor bleeding event was not different (6.7% vs 7.4%; P = 0.882). CONCLUSIONS: The heparin bridging therapy had significantly higher risk of major bleeding. Conflict of Interest: None declared.

P157: COMPLICATIONS OF ENDOSCOPIC INTERVENTIONS IN A CHOLEDOCHOLITHIASIS Andrey Kotovskiy1, Konstantin Glebov2, Tatiana Syumareva2 1

I.M. Sechenov Fist Moscow State Medical University, and O.M. Filatov Municipal Clinical Hospital No 15, Moscow, Russia 2

AIMS: Analysis of the results of endoscopic surgery in patients with choledocholithiasis. METHODS: Over the last 3 years analyzed the results of endoscopic surgery of 499 patients with choledocholithiasis. 82.8% of patients were diagnosed choledocholitiasis combined with calculous cholecystitis, and 17.2% identified recurrent and residual gall-stones. In 11.4% of choledocholithiasis is complicated by the development of acute suppurative cholangitis, the one with 13.2% in ampular part of duodenum were found periampular diverticula’s, and 2.2% had clinical signs of biliary pancreatitis.

RESULTS: In the early postoperative period we had complications were caused by the difficult anatomy-cal situation: multiple, large stones (15–20 mm in diameter), Mirrizi syndrome, intra-hepatic localization of stones, periampular diverticula’s, acute pancreatitis, bile duct strictures, bile duct tumors, bladder and pancreas tumors. The greatest number of complications (7%) was associated with onset of acute pancreatitis mainly caused by papillostenosis, acute biliary or chronic pancreatitis. Bleeding from the incision line were noted in 2.5% of cases, cases with latge stones or difficult manioulations and


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treated with conservative approach (medical, electrocautery, clipping). In 1.9% of patients in the postoperative period progressed phenomenon of acute suppurative cholangitis. Efficient way to eliminate this complication was the installation of nasobilliary drainage or stenting. In 3 patients (0.6%) diagnosed perforation of the duodenum, including 2 patients as a result of extended EPT and 1 - ruptured diverticulum during removal of calculus. 5 elderly patients (1%) died as a result of complications due to progression of purulent cholangitis, jaundice, despite the complete removal of stones from the bile ducts.

CONCLUSIONS: In 95% of cases the stones were removed after papillotomy (EPT), and 5% of patients endoscopic procedures were not sufficient and the patients were operated in the traditional way. Conflict of Interest: None declared.

P158: NEGATIVE ASPECTS OF ENDOSCOPIC STENTING Aleksey Balalykin1, Paul Barbado2 1

Central Military Hospital, Moscow, and 2Narofominsk State Hospital, Surgery, Naro Fominsk, Russia

AIMS: Nowadays stenting is widely used to treat a variety of problems of gastrointestinal, biliary tract and others. Special attention is paid on self-expanding metallic stents. The aim of study is to report our experience of biliary stenting and to give overview on and classify negative aspects we encountered.

METHODS: Plastic stents are used in 2100 procedures, metallic stents - in 40. Overall success rate is 97%, rate of complications is 2.5%. 281 patient was included in study - 192 of them undergone biliary stenting using plastic stents, other using metallic stents.

RESULTS: Following problems were detected and classified. Problems of organization:

1. 2. 3. 4. 5. 6. 7.

Organisation of operating room Anesthetic management Necessity in modern equipment and instruments Large surgical team Expensive equipment Amount of urgent procedures Medical insurance companies

Tactical problems of stenting:

1. 2. 3. 4. 5.

Radiation exposure Difficulty of procedures Preparation of operative field (EPT, dilatation) Limited functioning time Long-term postoperative management

6. Migration of stent 7. Necessity in replacement of stent 8. Defects of deployment Negative aspects of stents:

1. 2. 3. 4. 5. 6. 7.

Expensiveness Difficulties of delivery Mechanical stress to endoscope Duration of procedure Delivery system malfunction Clinical limits of application Lack of expanding

Tactical issues:

1. Wrong stent type (covered or non-covered, inadequate recanalization etc.) 2. Incorrect stent positioning 3. Inadequate draining 4. Rejection of combined procedures leading to progress of infection, poor drainage and complications. Complications of stenting are:

1. 2. 3. 4. 5. 6. 7. 8.

Migration to the lumen (8–14%) Migration into other organs (0–2.5%) Stent occlusion (5–86%) Infection (2.5–7%) “Pressure sore” (1.4–2.5%) Perforation (3.7–6%) Internal fistula (0–4.6%) Acute cholecystitis (0.5–3%)

CONCLUSIONS: Stenting is important tool in treatment of different conditions, sometimes alternative to traditional surgical approach, but still expensive and difficult and have wide spectrum of severe complications. Conflict of Interest: None declared.

P159: COLONOSCOPIC PERFORATION: CAUSES, MANAGEMENT AND OUTCOME Mikhail Agapov, Konstantin Khalin, Alexandr Barsukov Vladivostok Clinical Railway Hospital, Vladivostok, Russia

AIMS: Perforation is one of the most serious and potentially fatal complications of both diagnostic and therapeutic colonoscopy. The aim of the study is to evaluate causes, methods of treatment and outcome of large bowel perforation associated with colonoscopy.




METHODS: A retrospective analysis of patients treated in Vladivostok railway clinical hospital from 2006 to July 2016 with large bowel perforation as a complication of colonoscopy has been made.

RESULTS: There were 23 cases of colonic perforations: 21 as a result of therapeutic (ESD - 9, EMR - 8, stenting - 2, balloon dilation - 1 and hot biopsy polypectomy - 1) and 2 - diagnostic colonoscopy. Sigmoid colon was the most frequent site of perforation in both diagnostic (100%) and therapeutic colonoscopy (38%). The complication was diagnosed early - during the procedure in 17 (73.9%), within 1 h after in 1 and later in 5 cases. In 9 cases the complication was successfully treated surgically in 14 - by endoscopic clipping. There was no any further morbidity and mortality associated with the complication. The mean perforation size was (9.4 1.5 mm), 14.7 2.9 mm in surgical arm and 6.0 0.7 mm in endoscopic clipping arm (P = 0.002). Late detection of perforation was positively associated with surgical treatment (5 out of 5 for late and 4 out 18 for early) P = 0.0037.

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0.68–0.7?1; >0.7?2 The total score is 17. Low risk (≤4), intermediate (5–8), high (9–13), very high (14–17).

RESULTS: 156 patients showed low risk score for OV (0–4); 36 patients (23%) showed GBS 2, showed no OV on upper endoscopy (UE). 6 patients showed an intermediate risk for OV (5–8); 2 patients showed OV (33.3%). 72 patients showed high risk for OV (9–13); OV was diagnosed in 68 (94.4%). 66 patients showed very high risk for OV (14–17); UE revealed OV in 66 (100%). Validation group: 20 patients with GBS = 0, with OV score 2.35 1.1 showed no OV; 11 patients with GBS ≥6, OV score 2.8 0.8 showed no OV; 19 patients with GBS ≥6, OV score 6.9 1.1; 8 patients showed OV (44.4%); 50 patients with GBS ≥6, OV score 12.3 1.9; 47 patients (94%) showed OV.

CONCLUSIONS: The score was highly efficacious in identifying critically ill patients who will benefit from therapeutic endoscopic intervention due to bleeding varices. Conflict of Interest: None declared.

CONCLUSIONS: Endoscopic clipping is an effective method of colonic perforation treatment. Although late diagnosis and larger defect size is associated with the necessity of surgical repair. Conflict of Interest: None declared.

P161: BLEEDING AS A COMPLICATION AFTER UPPER GI POLYPECTOMY Alexander Katzarov1, Dimitar Takov1, Zdravko Dunkov1, Ivan Popadiin1, Krum Katzarov1, Emilia Naseva2 1

P160: RISK STRATIFICATION FOR PRIORITY OF UPPER ENDOSCOPY AND ESOPHAGEAL VARICES PREDICTION IN HIGH RISK PATIENTS WITH MEDICAL CO-MORBIDITIES BY OV-METRIC AND GLASGOW BLATCHFORD SCORES 1

1

Amr Hanafy , Waseem Seleem , Mohammad Basha

2

Zagazig University 1Internal Medicine - Gastroenterology Unit, and 2Diagnostic Radiology, Zagazig, Egypt

AIMS: Patients with advanced co-morbidities could be presented with upper GIT bleeding (UGB); however this could be hazardous if endoscopy performed unnecessarily, We aimed to validate a novel score for prediction of OV and risk stratification for endoscopic intervention. METHODS: 300 patients with systemic illness presented with UGB. Glasgow Blatchford score and OV metric score were calculated. A validation group (n = 100) was selected.

OV SCORE: Clinical: Splenomegaly (Absent=0, present=1), Child score (7 = 2), Laboratory data: AST/ALT ratio (1 = 1), platelets (>150 ?0; 100–150 ?1; 80- 100 ?2; 1 [OR 1.2], low prothrombin concentration < 50% [OR 1.5]. Intra-procedural factors as amount of ethanolamine >15.5 mL [OR 2.6], amacryate >3.5 mL [OR 2.9]. Postprocedural factors within 24 hours after endoscopy as leucocytosis >12.000 cell/ul [OR 1.9], drop of hemoglobin >10% of the pre-endoscopic value [OR 3.2], prolonged INR >1.55 [OR 1.2]. CONCLUSIONS: Bleeding related to sclerosant ulcers is not uncommon, but may be life threatening. The proposed predictive factors should be watched and minimized before and during variceal sclerotherapy. Conflict of Interest: None declared.

CONCLUSIONS: With increasing prevalence of obesity and advances in endoscopic modalities for obesity management,



P164: PULMONARY CHANGES ASSOCIATED WITH INJECTION SCLEROTHERAPY OF GASTRIC FUNDIC VARICES Ahmed Mohammed El Nakib Mansoura University, Mansoura, Egypt

AIMS: To assess the pulmonary changes associated with endoscopic injection sclerotherapy of gastric fundic varices using undiluted N- Butyl- Cyanoacrylate. METHODS: Out of 90 patients who were admitted to Tropical Medicine Department, Mansoura University Hospitals only fourty patients were inrolled in this study. Patients were grouped into; group I including 20 patients with gastricfundicvarices with previous history of hematemesis and/or melena and treated with injection sclerotherapy by using undiluted NButyl Cyanoacrylate (NBCA) and group II including 20 patients underwent diagnostic upper GIT endoscopy for detection of varices. Patients were subjected to pulmonary function tests including Diffusion of Lung using Carbon monoxide (DLCO) the day before and one week after endoscopic procedure.

RESULTS: The results revealed significant decrease inForced Expiratory Volume 1 (FEV1) and Forced Vital Capacity (FVC) (P ˂ 0.05) and Diffusion of Lung using Carbon monoxide (DLCO) (P ˂ 0.05) while no significant change in ratio between FEV1/FVC%( P = 0.16) in group I after procedure. There was no significant decrease in FEV1 and FVC (P = 0.3) and DLCO was constant and no significant change in ratio between FEV1/FVC%( P = 0.3) in group II after endoscopy. Four patients in group I developed mild pleural effusion and only one patient developed atelectitic band after procedure whileno significant difference in chest X ray and CT chest in patients in group II after endoscopy. CONCLUSIONS: After injection of gastric fundic varices using undiluted NBCA, there was a fall in FEV1 and FVC without any change in FEV1/ FVC ratio suggesting a restrictive pattern of pulmonary function test and significant fall in DLCO suggesting diffusion defect and about 20% of patients developed mild right sided pleural effusion and about 5% of patients developed atelectitic band. Conflict of Interest: None declared.


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January 2012 to July 2014. The inclusion criteria were single or multiple polyps with size equal or larger than 10 mm. For our study period there were 1667 polypectomies performed from our team. From those 420 procedures fulfilled the inclusion criteria. A complete follow up was obtained in all of the cases. We used Fisher’s exact test and Mann- Whitney U test for statistical analysis. In our cohort we assessed factors as patient gender, age, number of polyps, localization, size, type of current and technique used as independent risk factors for bleeding after polypectomy.

RESULTS: Twenty-four patients had immediate bleeding after polypectomy. There were no cases of delayed bleeding (defined as 24 h after polypectomy). There was statistically significant risk for bleeding in the cases where the localization of the polyp was observed in rectum and ascending colon. Lifting techniques (EMR, ESD) and larger size of the polyp were also statistically significant for bleeding, in the study. Localization in sigmoid colon, coagulation current, gender, age and number of polyps were no statistically significant. All cases of bleeding were managed endoscopically with single or multiple hemostasis techniques. CONCLUSIONS: According to our study endoscopic team can expect higher risk for bleeding associated with localization, size, current and technique used. Managing the patients with these risk factors as high risk patients would lead to better management and outcome. Conflict of Interest: None declared.

P166V: ENDOSCOPIC REMOVAL OF AN EMBEDDED ESOPHAGEAL STENT AFTER PLACEMENT FOR POST ESOPHAGECTOMY LEAK Nitin Pai Ruby Hall Clinic, Gastroenterology, Pune, India

AIMS: The feasibility of an endoscopic removal of an impacted esophageal stent following placement in a case of post surgical esophageal leak. METHODS:

P165: BLEEDING AS A COMPLICATION IN THERAPEUTIC LOWER GI ENDOSCOPY Alexander Katzarov1, Dimitar Takov1, Zdravko Dunkov1, Ivan Popadiin1, Krum Katzarov1, Emila Naseva2 1

Military Medical Academy, Gastroenterology, and 2Medical University of Sofia, Faculty of Public Health, Sofia, Bulgaria

AIMS: To assess the risk factors associated with bleeding after polypectomy in lower GI. METHODS: The study was done retrospective and prospective and was conducted at Military Medical Academy Sofia from

1. 50 year old Male with history of CA esophagus operated in May 2014. 2. Had anastomotic leak on D4 of esophagectomy. 3. Placed a covered esophageal stent to cover leak (outside-HANARO fully covered stent). 4. Stormy morbid post operative phase. 5. Discharge 3 weeks later. 6. Advised to come for removal of stent after 7 more days. 7. Lost to follow up. 8. Sept 2014-came for dysphagia-impacted stent-


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removal attempted-broke the lasso-stent got disfigured-procedure abandoned. 9. Came back In Nov 2014 for persistent vomittings. 10. OGD-revealed impacted stent in gastric tube with in growth at lower end. 11. Endoscopic removal planned. RESULTS: Endoscopic removal –3 steps used. 1. Release of stent from all around circumferentially along length of stent. 2. Cutting of all ingrowth tissue at lower end. 3. ESD/EFTR of stent from gastric tube in the space between stent and stomach wall. Ultimately with APC help a complete endoscopic removal of a fully embedded stent was achieved-defect could be closed with clips

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 under nourished females and graded dilatation was done using 30 & 35 mm balloons. Both were managed conservatively keeping NPO, IV fluids, IV antibiotics, left pleural drains and esophageal stent placement, with anchoring of upper end tied with thread, to prevent migration. NJ tubes were placed in the same sitting and feeding started on second day of placement. Antireflux SEMS were used in both the patients, placed on day 4 and day 2 and removed on day 14 and day 10 respectively. Both the patients recovered completely.

CONCLUSIONS: Esophageal perforation is an uncommon complication of pneumatic dilatation of achalasia cardia. It can be successfully managed with covered self expanding metallic stent placement along with NJ feeding, IV fluid and antibiotics. Conflict of Interest: None declared.

CONCLUSIONS: Impacted esophageal stent is a nightmare for removal. Complete endoscopic removal could be achieved with ESD / EFTR and APC with safe and good results. Take home messages-Relatively easy to release ingrowth. APC helps in stent breakage-but uncontrolled. EFTR was rather done boldly as post op all structures are plastered along gastric wall-no fear of full thickness tear/ vascular structure in close vicinity. Closure was achieved with available endoscopic devices safely. Conflict of Interest: None declared.

CLINICAL ENDOSCOPIC PRACTICE: ENDOSCOPY: MANAGING LEAKS AND FISTULAE

P167: ESOPHAGEAL PERFORATION AFTER ENDOSCOPIC BALLOON DILATATION FOR ACHALASIA SUCCESSFULLY MANAGED WITH ESOPHAGEAL SEMS

1 Gemelli University Hospital - Catholic University of Rome, Digestive Endoscopy Unit, Rome, Italy and 2IHU - USIAS Strasbourg University, Strasbourg, France

Sanjay Kumar1, Pravin Borasadia1, Ajeet Sewkani2, Sandesh Sharma2 1

Gastrocare Liver & Digestive Disease Centre, Medical Gastroenterology, and 2Gastrocare Liver & Digestive Disease Centre, Surgical Gastroenterology, Bhopal, India

AIMS: To report our experience with non surgical management using SEMS for post balloon dilation esophageal perforation for achalasia cardia.

METHODS: Esophageal perforation following pneumatic dilatation for achalasia cardia, although uncommon, is a devastating complication, reported to occur in 0–10%. It needs utmost vigilance, as early recognition and timely intervention are the key to successful management. Non surgical management of such perforations is described in literature by conservative treatment with or without stent. We report two such cases successfully managed with SEMS. During a period from 2007 to 2016, pneumatic dilatation was done in 96 patients.

RESULTS: Out of 96 dilatations, all were uncomplicated except 5 patients. Three had significant post procedure pain, however perforation was ruled out. Two had esophageal perforation, both recognized during procedure. Both the patients were

P168: ENDOSCOPIC TREATMENT OF POSTLAPAROSCOPIC SLEEVE GASTRECTOMY LEAKS WITH A SPECIFICALLY DESIGNED METAL STENT Vincenzo Bove1, Andrea Tringali1, Rosario Landi1, Vincenzo Perri1, Ivo Boskoski1, Pietro Familiari1, Federico Barbaro1, Guido Costamagna1,2

AIMS: Leak of the surgical suture at the level of the esophagogastric junction is the main complication of Laparoscopic Sleeve Gastrectomy (LSG). The efficacy of a specifically designed Fully Covered Self-Expandable Metal Stent (FC-SEMS) as a first line therapy in post-LSG leaks is evaluated. METHODS: Patients referred to our Endoscopy Unit from Jan2013 to Nov2015 for the treatment of post-LSG fistula underwent insertion of a specifically designed FC-SEMS (Niti-S Beta stent, Taewoong Medical, Seoul, Korea). This stent has a small cell meshes, a specific design with anti-migration features and a length between 18 and 23 cm to extend from the esophagus to the antrum, in order to bypass the leak; stent diameter is 24 mm (32 mm proximal flared end) to have an optimal adherence to the esophagus.

RESULTS: Ten patients (5 males, mean age 32.1 years, range 20–53) (mean BMI 43.11) were treated. A total of 11 SEMS were inserted. In 8 patients (80%) the fistula healed after stent removal. Two patients (20%) had fistula recurrence after 8 and 14 days from stent insertion; they were treated with a FC-SEMS with wide cells meshes. In one case proximal dysfunction of the stent was diagnosed, the stent was removed and replaced with the same FC-SEMS but with small meshes design, obtaining subsequent fistula healing. The


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 second patient had also proximal stent dysfunction leading to the development of an infected 4 cm collection; 2 doublepigtails plastic stents were inserted from the leak to the collection obtaining an internal drainage; fistula healing was observed after plastic stents removal. After a mean follow-up of 13 months (range 5–37) all the patients are asymptomatic.

CONCLUSIONS: A specifically designed esophago-gastric FCSEMS with a small cells design is an effective and promising treatment for post-LSG leaks, but needs further evaluation in large series and in the setting of clinical trials. Conflict of Interest: None declared.

P169: PANCREATIC PSEUDOCYSTS DILEMMA: CUMULATIVE MULTICENTER EXPERIENCE IN MANAGEMENT USING ENDOSCOPY, LAPAROSCOPY AND OPEN SURGERY Alaa Redwan Sohag University, GIT Surgery and Laparo-Endoscopy, Sohag, El Salvador

AIMS: Exploring the minimally invasive techniques in treatment of pancreatic pseudocysts, namely endoscopic and laparoscopic routs, and comparing them to open surgical therapy. METHODS: Fifty nine patients with pancreatic pseudocysts were included in this study. Thirty five patients were treated endoscopically, two laparoscopically and twenty two by open surgery. The endoscopic techniques used were cystogastrostomy in twenty cases and cystoduodenostomy in two. In the laparoscopic cases, loop-sutured cystojejunostomy was done. The open surgical techniques were cystogastrostomy in fifteen patients and cystojejunostomy in seven.

RESULTS: The endoscopic therapy had the shortest procedure time (30 min) in comparison to 110 and 105 min for the laparoscopic and open surgical groups respectively. No mortality was reported in any of the groups. Postoperative complications represent 14%, 40% for the endoscopic and the open surgical groups respectively. The laparoscopic case had no complications. The hospital stay was shorter for both endoscopic and laparoscopic cases than open surgical cases.


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P170: SAFETY AND EFFICACY OF OVER THE SCOPE CLIP IN HAEMOSTASIS OF GASTROINTESTINAL BLEEDING AND CLOSURE OF LEAKS AND FISTULA Mahesh Goenka1, Vijay Rai1, Usha Goenka2, Indrajit Tiwari1 1

Apollo Gleneagles Hospitals, Institute of Gastrosciences, and 2Apollo Gleneagles Hospitals, Department of Clinical Imaging and Interventional Radiology, Kolkata, India

AIMS: Over-The-Scope Clip (OTSC) is a device with applications for endoscopic closure of perforations/ leaks/fistulas and for hemostasis of non variceal gastrointestinal bleeding. The aim of the study is to evaluate the clinical efficacy and safety of OTSC. METHODS: Between October 2013 and February 2016, 19 patients underwent OTSC placement by an experienced endoscopist. OTSC was used for the closure of Gastrointestinal (GI) leaks and fistula in 8 patients, 4 of these were iatrogenic (esophageal, gastric and duodenal) and 3 were inflammatory and one was traumatic. In 11 patients, OTSC was used for haemostasis of non variceal upper GI bleeding.

RESULTS: All procedures related to haemostasis achieved immediate as well as long term clinical success. 3 patients who were on anti platelet medications were continued with anti platelet drugs after application of clip without any rebleeding. 6 out of 8 cases of GI defect, achieved immediate as well as long term success. In 2 cases, success was partial as additional procedures required for the closure of defect. One patient with post inflammatory colonic defect, fully covered self expandable metal stent was required; and in one patient with duodenal defect, glue injection was required to close the defect. Only one clip was required to close each of the GI defects and to achieve haemostasis in all patients. The procedure was well tolerated and patients were hospitalized for an average 6 days (range: 3– 11 days). During follow up (mean: 8 weeks, range: 5– 21 weeks), permanent closure of all fistula and leaks was achieved in all but one patient and no rebleeding occurred in any of the GI bleeding cases. CONCLUSIONS: In our experience, OTSC was safe and effective in haemostasis of non variceal GI bleeding especially in patients on coronary stent with ant platelet medications. OTSC clips effective for closure of GI leaks and fistula as well. Conflict of Interest: None declared.

CONCLUSIONS: Because of the limited number of cases, definitive comparative results cannot be concluded. However, it can be stated that minimally invasive therapeutic techniques, whether endoscopic or laparoscopic, for pancreatic pseudocyst could be considered valuable, competitive and promising alternatives for open surgery. Large scale comparative studies are highly recommended in the future. Conflict of Interest: None declared.


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P171: ANALYSIS OF ENDOSCOPIC STENT AS THERAPY FOR FISTULA AFTER GASTRIC BYPASS vio Coelho Ferreira1, Josemberg Campos1, Eduardo Sa vio Fla Nascimento Godoy1, Delgis Arias Martınez1, Lyz Bezerra Silva1, Helga Cristina Almeida Wahnon Alhinho1, Cinthia Barbosa de Andrade1, Helaine Cibelle Tolentino de Souza1, Joana Cristina Silva1, Alvaro Antonio Bandeira Ferraz1, ~o-Neto2 Manoel Dos Passos Galva 1

2

Universidade Federal de Pernambuco, Recife, and Gastro ~ o Paulo, Brazil Obeso Center, Sa

AIMS: Gastric leak is one of the most serious complications after bariatric surgery, associated with high morbidity and mortality, that can be treated by support intervention, endoscopy, and/or surgery. Stenting of the leak site is one tenet of endoscopic treatment with good results despite the fact that stent models are not developed to surgical anatomy. This study aims evaluate therapeutic aspects of endoscopic stenting of leaks after Roux en Y gastric bypass, the association between time of healing and early use of stent, to identify benefits of early use and removal of stents. METHODS: Retrospective study of 103 patients with leaks after bariatric surgery. Eighteen of these patients received treatment for leak after Roux en Y gastric bypass through endoscopic stenting, between 2002 and 2014.

RESULTS: Twenty-two stents were used and remained on site for 31.7 14.7 days. Average age was 39.72 years (31–57) and Body Mass Index of 42.79 kg/m2 (35.33–62.24). Time between fistula and stenting had a median of 22.9 27.0 while the time of fistula diagnosis was 6.3 3.9 after surgery. Stents used were self-expandable plastic stents (61.9%), fully covered self-expandable metallic stents (23.8%) and partially covered (14.3%), with 27.7% migration rate. CONCLUSIONS: Endoscopic treatment with stenting of fistulas after Roux en Y gastric bypass is feasible and safe, with global success of 94.4%. Shorter healing time was observed in patients that received early stents and had leaks under 10 mm of diameter. Conflict of Interest: None declared.

both diagnostic as well as therapeutic purposes, but with the advent of better imaging modalities pancreatic endotherapy is mainly used for therapeutic uses like pancreatic stenting or cystogastrostomy in cases of ductal leak. Selection of patients is very important for endotherapy. It is successful in majority of patients who are selected properly for endotherapy and avoids surgery in these group of patients.

METHODS: Retrospective and prospective, observational study. Study period from Jan 2011 to Jul 2016. Study centreMadras Medical College and Rajiv Gandhi Government General Hospital. Patients with pancreatitis (Acute / Recurrent acute / Acute on chronic / Chronic pancreatitis) with pancreatic ductal leak (Communicating pseudocyst/ Pancreatic ascites /Pancreaticocutaneous fistula/Pancreatico-pleural fistula/ Post trauma pancreatic duct leaks) who underwent endotherapy were included in this study. In all these patients pancreatic ductal leak / communication/fistulas has been demonstrated either by imaging or by ERP or by both.

RESULTS: Total of 60 patients who underwent pancreatic endotherapy were included for analysis, out of which 48 were males and 12 were females. 40 patients had communicating pseudocyst-infected, 09 had pancreatic ascitis, 06 had both pseudocyst and pancreatic ascitis.05 patients developed pancreatic fistulas due to trauma. In 30 patients pancreatic ductal leak has been managed with pancreatic duct stenting. 16 patients with infected pseudocyst, who failed transpapillary drainage underwent endoscopic cysto-gastrostomy. Remaining 14 patients referred for surgical intervention as the endotherapy was not successful. Endotherapy was successful in 73% patients in our centre. CONCLUSIONS: Pancreatic endotherapy was successful in 73% of our patients. Surgical intervention can be avoided in majority of patients with pancreatic ductal leak. Proper selection of patients is very important. Better imaging modalities made ERP mainly as therapeutic intervention in pancreatic ductal leak. Conflict of Interest: None declared.

CLINICAL ENDOSCOPIC PRACTICE: ENDOSCOPY: OUTCOMES P172: BRIDGING THE LEAK-PANCREATIC ENDOTHERAPY IN TERTIARY CARE CENTRE Natarajan Thirumoorthi1, Karunakaran Premkumar2, Thangavelu Pugazhendhi2, Ratnakar Kini2, Mohammed Kani Sheikh2, Mohammed Ali2 Madras Medical College 1Institute of Medical Gastroenterology, and 2Medical Gastroenterology, Chennai, India

AIMS: Pancreatic endotherapy plays a very important role in managing patients with pancreatic ductal leak. It is used for

P173: INCIDENCE OF ESOPHAGUS AND GASTRIC PATHOLOGY IN SYMPTOMATIC PATIENTS: RAJAVITHI’S HOSPITAL Ratchamon Pinyoteppratarn, Morakot Bandittonsakul, Siripong Sirikurnpiboon, Ratanachu-Ek Thawee Rajavithi Hospital, Surgery, Bangkok, Thailand

AIMS: Upper Gastrointestinal tract cancer is the common cause of cancer-related deaths in Asia. Esophagogastroduodenoscopy (EGDS) is an effective technique for detecting any lesions especially in symptomatic populations. The current


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 guidelines recommend that any patient with dyspepsia and alarm symptoms should undergo EGDS. The purpose of this study is to compare endoscopic findings with esophageal and gastric cancer incidence and other lesions while taking into account other factors such as age, gender, and the presence of alarm symptoms.

METHODS: A retrospective review of patients who underwent EGDS in Rajavithi’s hospital from 2010 to 2015 using information obtained from medical records. Symptomatic patients with aged over 18 years old with no history of esophageal or gastric cancer were selected. Data included were endoscopic finding, histological examination, diagnosis and management was obtained. All participants underwent biopsies for rapid urea test (RUT) and also further biopsies if presence of any visible lesions for histo-pathological evaluation.

RESULTS: During the study interval, 2000 symptomatic patients underwent EGDS (970 women, 1030 men) with a mean age of 55.49 years (range: 18–93 years). H. pylori infection was positive in 26.6%. EGDS findings were normal 12.8%, mass 21.6%, ulceration 20.2%, inflammation 38.2% bleeding 6.6%. Pathological findings were inflammation 15.6%, squamous cell carcinoma (SCC) 11.2%, adenocarcinoma 7.4%, precancerous lesion 0.6%. Gastric adenocarcinoma and squamous cell carcinoma of esophagus were detected in 7.4% and 11.2%, respectively. Gastric cancer and esophageal cancer in early stage, stage II, III and advance stage were 0.4, 16.4, 2.1 and 0.4. CONCLUSIONS: In patients with alarm symptoms it is feasible to implement early detection and treatment by endoscopic screening. Screening can identify potential early stage carcinoma and precancerous lesions, improving efficacy through early detection and treatment. The exploratory analysis of related influential factors will help broad implementation of early detection and treatment for esophageal and gastric carcinoma. Conflict of Interest: None declared.


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METHODS: Case notes of 320 consecutive patients who presented to the principal author’s unit at Sri Jayewardenepura General Hospital, Sri Lanka for upper gastrointestinal endoscopy for various reasons from 31/12/2013 to 31/12/2014 were retrospectively analyzed. Inclusion criteria were bothersome postprandial fullness, epigastricpain, epigastric burning and early satiety lasting for at least 6 months. Exclusion criteria were steroid therapy, nonsteroidal anti-inflammatory drug therapy, alcohol consumption, variceal surveillance and known upper gastrointestinal structural abnormalities. Accordingly 162 patients were selected for the study.

RESULTS: Total study population was 162 with an age range of 20–84 years, with a mean of 53.43 14.96 SD years. The sex ratio was male: female–9:7. When upper gastrointestinal endoscopy was performed, 6.13% had normal endoscopy, thus constituting the functional bowel disorder cohort, fulfilling the ROME III criteria.93.87%had endoscopic abnormalities. Viz, 41.73%, 44.10%, 61.90% and 78.00% had hiatus hernia, esophagitis, duodenitis, and gastritis respectively with overlaps. In the functional bowel disorder group age range was 24– 80 years with a mean of 55.90 15.48 SD years. The sex ratio was male: female –3:2. CONCLUSIONS: The prevalence of upper gastrointestinal functional bowel disorders seems to be low in this hospital based sample, in comparison to community based published studies from Indian subcontinent and worldwide. Conflict of Interest: None declared.

P175: NUTRITIVE VALUES AND CONSUMPTION PATTERN OF THE EDIBLE WILD PLANT (SPHENOSTYLIS MAGNATA) OF NALIKULI (LILONGWE) Emmanuel Gooms Mwase1, Benard Kamanga2 University of Livingstonia 1Basic Sciences, and 2Food and Nutrition, Mzuzu, Malawi

P174: THE PREVALENCE OF FUNCTIONAL UPPER GASTROINTESTINAL DISORDERS IN A COHORT OF ADULT SRILANKANS: A HOSPITAL BASED PILOT STUDY Lavanya Rajagopala1, Ravindra Satharasinghe2, Ajith Kumara Kiringodage2 National Hospital SriLanka, Clinical Medicine, and 2Sri Jeyawardenapura General Hospital, Clinical Medicine, Colombo, Sri Lanka 1

AIMS: The published community based studies of functional upper gastrointestinal bowel disorders have shown prevalence of 20–30% worldwide, 30.4% in India and 12.6% in Sri Lanka. There are no data on hospital based studies. Hence, this study was designed to assess the prevalence of functional upper gastrointestinal disorders among a cohort of adult Sri Lankans presented to a tertiary referral Centre.

AIMS: Determine the nutritive values of the plant in terms of vitamin C, magnesium, calcium, iron, phosphorus, crude fats, crude protein and iron. Establish conservation status of the edible wild plant. Determine its consumption pattern of the edible wild plant known as sphenostylis magnata found in Nalikuli area in Lilongwe, Malawi. METHODS: Using Atomic Absorption Spectrometer, UV-VIS spectrophotometer, Soxhlate and titration methods for food nutrients. Using questionnaires to establish its conservation status and consumption pattern.

RESULTS: The results obtained were as follows: Mg = 260 0.05, Fe = 6.5 0.013, P = 94.5 0.013, K = 253 0.68, Ca = 45.18 0.05, Crude protein = 19.38 0.15, Crude fats = 5.1 0.21 and vitamin C


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= 17.18 0.05. Results of the survey revealed that 90% of the respondents had knowledge on its consumptive use and harvested frequently for consumption and this has led to its overuse and subsequent scarcity now.

CONCLUSIONS: The study has shown that wild edible plants can therefore provide minerals, vitamins or micronutrients without searching for expensive commercial food stuffs and thereby reduce malnutrition. The loss of the plant has caused many Malawians to lose a cheap source of minerals, vitamins or micronutrients from wild edible plants. However the plant is not only found in Lilongwe but also available in Kasungu, Zomba, Blantyre, Chiradzulo, Mzimba, Nkhotakota, Dedza Hills and Phalombe. Consumption of the wild edible plant can be replacement of the commercial foods. The commercial foods are often expensive to be taken by a local Malawian. Conflict of Interest: None declared.

P176: ENDOSCOPIC MUCOSAL RESECTION FOR NEUROENDOCRINE TUMORS OF GASTROINTESTINAL TRACT Kamran Bagheri Lankarani1,2, Gholam Reza Sivand Zadeh1,2, Bita Geramizadeh1


P177: IMMEDIATE AND LONG-TERM RESULTS OF ENDOSCOPIC SURGERY FOR SUBMUCOSAL TUMORS OF THE UPPER GASTROINTESTINAL TRACT Sergey Shapovalyanz, Roman Plakhov, Evgeny Fedorov, Evgeny Gorbachev, Mikhail Timofeev, Oleg Yudin, Zalina Galkova, Stanislav Budzinsky, Ekaterina Ivanova, Ermek Ernazarov, Elena Guseva Pirogov Russian National Research Medical University. Moscow University Hospital N 31, Moscow, Russia

AIMS: Development of endoscopic methods allowed to review the tactical approach and capabilities of endoscopic surgery for submucosal tumors (SMT). METHODS: From I.1999 to VI.2016 we have examined 303 patients with SMT of the upper gastrointestinal tract; 130 (42.9%) of them were operated. Laparotomy have been done in 51 (39.2%) of them; endosurgical removal - in other 79 (60.8%) (m–11, f–68; ranged 27–77 years; mean age 59.5 + 9 years). From these 79 patients tumor was complicated by GI bleeding in 8 (10.1%) and pyloric stenosis in 2 (2.5%). The location of SMT was the following: esophagus-6 (7.6%), stomach-62 (78.5%), duodenum-11 (13.9%). The tumor size ranged from 5 to 86 mm (mean size 38.5 22.1 mm).

RESULTS: During this period 27 cases of NET were removed with endoscopic mucosal resection. Of them 11 were female. Age range was from 9 to 84 years of age (35 14). Of these tumors 22 were G1, 3 were G2, and 2 were Cancer. The latter two with cancer were referred for surgery. The locations were duodenum 9 cases, stomach: 10, rectum: 5, ileum: 3 cases. All lesions were less than 20 mm. With a median follow up of 6 months no recurrence was find till now by endoscopic as well as follow up trans abdominal sonography on 3 months interval and CT scan on 6 months intervals.

RESULTS: Data of preoperative EUS allowed to attempt intraluminal removal of SMT in 57 and do remove them in 55 (69.6%) patients, utilizing various types of snare EMR in 29 cases (including 4 under laparoscopic control); ESD in 22; SETR in 4 cases. Others 24 (30.4%) underwent laparoscopic interventions (among them 4 via da Vinci Robotic System). Intraoperative complications occurred during endoscopic removal in 2 cases: intensive bleeding was stopped endoscopically; perforation of the stomach was sutured by endoclips and amplified by laparoscopic suturing. Postoperative complications were observed in 2 cases after laparoscopic interventions: leakage of the gastric suture line, peritonitis, sepsis, lethal outcome- 1; pyloric stenosis, requiring conservative treatment- 1. Mortality was 1.26% (1/79). Results of morphology and immunohistochemistry: GIST-30 (38.0%); leiomyoma-20 (25.3%); fibroma-8 (10.1%); lipoma-7 (8.9%); inflammatory-fibrotic polyp-6 (7.6%); aberrant pancreas-3 (3.8%); inflammatory myofibroblastic tumor -2 (2.5%); brunneroma-2 (2.5%); retention cyst-1 (1.3%). Longterm results (from 1 to 10 years, average 5.5 + 1.5 years) have been evaluated in 56 (70.9%) patients. Recurrent (most likely residual) GIST was observed 2 years after partial laparoscopic resection only in 1 case; laparotomy, subtotal gastrectomy. No other relapses.

CONCLUSIONS: EMR could be considered as a safe method

CONCLUSIONS: Application of modern diagnostic and ther-

for treatment of NET of GIT. Conflict of Interest: None declared.

apeutic endoscopic methods allowed minimally invasive removal of SMT in more than half of patients, but they still need further validation Conflict of Interest: None declared.

1

Shiraz University of Medical Sciences, and 2Health Policy Research Center, Shiraz, Iran

AIMS: Neuroendocrine tumors (NET) of gastrointestinal tract (GIT) are increasingly more recognized. For those with localized disease, endoscopic mucosal resection is an interesting option. METHODS: From March 2014 to March 2015 we prospectively studied cases with localized NET in GIT. EUS and transabdominal sonography were used to exclude patients with advanced disease.




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P178: METALLIC STENTS IN OESOPHAGEAL CANCER IN SUDAN

The primary outcome was stent patency, patient survival, and 30day mortality, with additional numerous secondary outcomes.

Mohammed Mohammed1, Bushra Ibnaouf2, Sara Alfadil3, Isam Mohammed4, Suliman Fedail5

METHODS: We performed a systematic search of MEDLINE,

1

2

Nile Valley University, Medicine, Atbara, University of Khartoum, Medicine, Khartoum, 3Soba University Hospital, Medicine, Khartoum, 4Ibnsina Specialized Hospital, Gastroentrology, Khartoum, and 5Fedail Hospital, Gastroentrology, Khartoum, Sudan

AIMS: To evaluate feasibility, efficacy and safety of metal stents in the management of oesphageal cancer in Sudan.

METHODS: Retrospective study. All patients who had metallic stents for oesphageal cancer were included. Institution: Fedail Hospital - Khartoum- Sudan. A tertiary referral private hospital. Study conducted from Jan 2010 - Oct 2014. All patients are unfit or unwilling to have surgery due to unresectable tumors, distant metastasis, poor functional status or recurrence after surgery.

RESULTS: Total number of patient 161 Males 92 = 57%) Females 69 = 43%, Mean age 63 years range (15–90) years. 16% below age of 50%. Squamous cell carcinoma represent 103 (64%) were adenocarcinoma 55 (34%) unclassified 3 (1.9%). 90 % of tumour are between 30–40 cm from incisor 40% has malignant esophageal respiratory fistulas. Historically 90% of oesophageal cancer is squamous. Our series - most cases of adenocarcinoma are Ca Stomach extending into oesohpagus. Approximately 80% of our patients had dysphagia score 3 or 4. The stent employed is Bonastent South Korea, Stent without anti-reflux valve 116 = 72% Stent with anti-reflux valve 45 = 28% Technical success rate = 98%. Intra procedual: Death 1 patient - sedation related. And 8 patients mal-positioning - Post procedual Adverse Event. Chest pain occur in 80%, Foreign body sensation in 7 patients. One patient develop Subcutaneous emphysema Delayed Adverse Even Migration: in 3 Patients Food occlusion in 12 patients and Tissue overgrowthin 6 patient.

CONCLUSIONS: Metallic stent are feasible in resource poor countries. Metallic stent are cost effective. Metallic stents provide better quality of life than surgically inserted tubes. Conflict of Interest: None declared.

P179: PLASTIC VS SELF-EXPANDABLE METAL STENTS FOR PALLIATION IN MALIGNANT BILIARY OBSTRUCTION: A SERIES OF META-ANALYSES Magid Almadi1,2, Alan Barkun1, Myriam Martel1 1 2

McGill University Health Center, Montreal, Canada and King Khalid University Hospital, Riyadh, Saudi Arabia

AIMS: Self-expandable metal stents (SEMS) are thought to have an advantage over plastic stents in achieving biliary drainage. .

EMBASE, Scopus, CENTRAL, and ISI Web of knowledge databases, from January 1980 to September 2015, for randomized trials (RCTs) comparing SEMS vs plastic stents vs in the palliation of malignant biliary obstruction. Primary outcomes were durations of stent patency, of patient survival, and 30-day mortality. Numerous secondary outcomes were assessed and extensive sensitivity and subgroup analyses performed.

RESULTS: Twenty RCTs totaling 1713 patients yielded a weighted mean difference (WMD) in time to stent patency of 4.45 months (95%CI, 0.31; 8.59) favoring SEMS with greater benefit at initial drainage attempt. SEMS use resulted in lower rates of late complications OR=0.43 (95%CI, 0.26; 0.71), sepsis or cholangitis OR=0.53 (95%CI, 0.37; 0.77), blocking from sludge OR=0.11 (95% CI, 0.07; 0.17), mean number of re-interventions WMD = –0.83 (95% CI, –1.64; –0.02), and a higher symptom free survival at 6-months OR=5.96 (95%CI, 1.71; 20.81). There were no differences in overall patient survival or 30-day mortality, yet survival benefits were noted for uncovered but not partially or fully covered SEMS vs plastic stents, and for SEMS in the setting of pre- or post-procedural antibiotic administration, and performance of a sphincterotomy. CONCLUSIONS: The use of SEMS compared with plastic stents, in the palliation of patients with malignant biliary obstruction results in longer stent patency, less complications and fewer re-interventions, while exhibiting survival benefits in selected subgroups of patients. Conflict of Interest: None declared.

P180: NOVEL ORAL ANTICOAGULANTS AND GASTROINTESTINAL BLEEDING: A META-ANALYSIS Corey Miller, Alastair Dorreen, Myriam Martel, Thao Huynh, Alan Barkun McGill University Health Center, Montreal, Canada

AIMS: Several novel oral anticoagulants (NOACs) have been approved for clinical use or are in advanced-phase clinical trials, yet evidence regarding associated risk of gastrointestinal (GI) bleeding is limited. To determine the risk of GI bleeding associated with NOACs as compared to conventional anticoagulation therapy. METHODS: An initial search for randomized controlled trials comparing NOACs to conventional anticoagulation therapy was performed using the EMBASE, Medline, Cochrane and ISI Web of knowledge databases through January 2016. NOACs already approved or in active development were included. Trials assessing NOACs for the treatment of acute coronary syndrome and other unapproved indications were excluded. A metaanalysis was conducted with results reported as odds ratios (OR) with 95% confidence intervals (CI). The primary outcome was major GI bleeding. Secondary outcomes included clinically-


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relevant non-major (CRNM), upper and lower GI bleeding. A priori subgroup analyses by individual NOAC were performed.

RESULTS: An initial search yielded 1940 citations. We retained 43 trials which evaluated dabigatran, rivaroxaban, apixaban, edoxaban and betrixaban with 166,289 patients randomized. Between NOACs and conventional anticoagulation, there was no difference in major (OR 0.98, 0.80–1.21), CRNM (OR 0.93, 0.64–1.36), upper (OR 0.96, 0.77–1.20) or lower GI bleeding (OR 0.88, 0.67–1.15). An increased odds of major GI bleeding was associated with dabigatran (OR 1.27, 1.04–1.55) and rivaroxaban (OR 1.40, 1.15–1.70) compared to conventional anticoagulation, whereas no difference was found for apixaban (OR 0.81, 0.64–1.02) or edoxaban (OR 0.93, 0.78–1.11); however, these subgroup findings were not observed in other sensitivity analyses. CONCLUSIONS: Overall, major GI bleeding risk was found to be equivalent between NOACs and conventional anticoagulation. Dabigatran and rivaroxaban, however, may be associated with increased odds of major GI bleeding. Further high-quality studies are needed to further characterize GI bleeding risk among individual NOACs, taking patient characteristics into consideration, ideally in head-to-head trials. Conflict of Interest: None declared.

P181: A GASTRIC SUBMUCOSAL TUMOR-LIKE TUBERCULAR MASS ORIGINATED FROM THE SEPTUM TRANSVERSUM TREATED BY ENDOSCOPIC SUBMUCOSAL DISSECTION: A CASE REPORT Bingtuan Liu The First Affiliated Hospital of Nanjing Medical University, Nanjing, China

AIMS: We have an interesting gastric submucosal tumor (SMT)-like diaphragmatic tuberculosis case. A 77-year-old man presented with vague abdominal pain and general malaise that had lasted for about one year. He had no history of fever or cough prior to his presentations. His medical history was uneventful. His family history was unremarkable. In addition, review of system and physical examination results were unremarkable. We found a dumbbell-shaped “submucosal tumor” at gastric cardia next to the fundus of stomach by gastroscopy, the mucosal surface of which was smooth. A mixed echo with a integrated envelope was seen during endoscopic ultrasound, demonstrating an exophytic pattern of growth, toward the peritoneal cavity. No tube-like echo was seen in it. The section size was about 2.4 9 2.0 cm. Computed tomography (CT) scan revealed a negative result in gastric wall, and no ascitic fluid was found. Relevant blood test results were as follows: WBC3.18 9 109/L, RBC3.89 9 109/L, Lym cell 0.75 9 109/L, Plt 129 9 109/L, Hemoglobin (Hb) 127 g/L, All other routine biochemical tests, including liver function test, renal function test, and coagulation factor assay, were within the normal range in the serum. In comprehensive consideration of the results of CT scan, gastroscopy and endoscopic

ultrasound, we ruled out the diagnosis of aneurism, cyst, and other possibilities that could not or needed not to be treated. For complete resection of the SMT and accurate histological diagnosis, we tried to perform an endoscopic full-thickness resection (EFR). Intraoperative findings showed a pale mass closely combining with the deep muscularis propria layer origenated from the septum transversum. The patient transferred to laparoscopic operation in the end due to uncontrollable bleeding. Histological examination of the resected specimen revealed chronic granulomatous inflammation with necrosis and calcification. The result of acid-fast stainin ascertained the diagnosis of TB at last.

METHODS: No content. RESULTS: No content. CONCLUSIONS: No content. Conflict of Interest: None declared.

P182: THE FIRST REPORT ABOUT DIAGNOSIS AND TREATMENT OF EARLY GASTROINTESTINAL CANCER BY ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) IN VIETNAM: A LATE BUT VERY PROMISING BEGINNING Trung Tran Quang1, Huy Tran Van1, Nam Phan Trung1, Kohei Funasaka2, Ryoji Miyahara2, Hidemi Goto2, Tadayoshi Okimoto3, Kazunari Murakami3, Murali Rangan4 1

Hue University Hospital, Endoscopy Center, Hue, Viet Nam, Nagoya University, Graduate School of Medicine, Gastroenterology, Nagoya, Japan, 3Oita University Hospital, Gastroenterology, Oita, Japan and 4Apollo Speciality Hospital, Gastroenterology & Interventional Endoscopy, Tamil Nadu, India 2

AIMS: In Vietnam, gastrointestinal (GI) cancer is increasing as one of the leading causes of cancer related death. However, early gastrointestinal cancer (EGIC) is not widely-known. Data on accurate diagnosis and treatment of EGIC by ESD in Vietnam has not yet been published. Aim: To evaluate the usefulness of magnified chromoendoscopy, the effectiveness and safety of ESD in diagnosis and treatment of EGIC in central Vietnam. METHODS: We prospectively enrolled patients from January 2014 to August 2016 at Hue University Hospital who underwent magnified chromoendoscopy using modern endoscopy systems from Japan, Indigocarmine and Lugol’s Iodine. Patients who underwent ESD using specific knives were followed up carefully. All cases were diagnosed after consensus between endoscopists and pathologists from Vietnam and Japan.

RESULTS: Out of 33797 GI endoscopies done with magnified chromoendoscopy from January 2014 to August 2016, 44 cases (0.13%) were diagnosed to have EGIC, while no EGIC was detected in 20507 GI endoscopies performed without magnified chromoendoscopy between 2012 and 2013 (P < 0.05). Among


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 44 EGIC cases, there were 28 early gastric cancer (EGC), 7 early esophageal cancer, 9 early colorectal cancer. Of them, 70.5% of lesions were intramucosal (m) cancer. The predominant type was 0-IIc (38.6%). 93.2% had typical irregular changes in magnified chromoendoscopy images. Among EGC, mild chronic atrophic gastritis was found in 64.3% while severe chronic atrophic gastritis was found in only 2 cases. ESD and EMR were done in 17 and 8 cases respectively. All cases underwent enbloc resection. Two patients had controlled bleeding. None had perforation. Longest follow up was 32 months without any recurrence till now.

CONCLUSIONS: Magnified chromoendoscopy is helpful in detecting early gastrointestinal cancer. Treatment of by ESD being effective and safe will be widely available in Vietnam. A significant proportion of Vietnamese having EGC have a background of mild chronic atrophic gastritis. Conflict of Interest: None declared.

P183: UPPER GASTRO-INTESTINAL ENDOSCOPIC CHANGES AND PREVALENCE OF HELICOBACTER PYLORI IN TYPE 2 DIABETES MELLITUS PATIENTS WITH CHRONIC DYSPEPTIC SYMPTOMS Bhumika Vaishnav, Sameer Shaikh Dr. D. Y. Patil Medical College and University, Internal Medicine, Pune, India

AIMS: To study the upper GI endoscopic patterns, histopathological changes and prevalence of H. pylori infection in diabetic patients with chronic dyspepsia. METHODS: A hospital-based, cross-sectional study of 30 patients with Type 2 Diabetes Mellitus (T2DM) and 30 without T2DM referred for upper gastrointestinal endoscopy with chronic dyspeptic symptoms was done between November 2015 and May 2016. Institutional ethics committee clearance and informed, written consents from all participants were taken. All participants completed “Short form - Leeds dyspepsia questionnaire”. Biopsies were taken from oesophagus, fundus, body, antrum of stomach and duodenum. Rapid Urease test for H. Pylori was done on the antral biopsy specimen using commercially available kit. All statistical tests (Odds ratio, Chisquare test, One-way Anova) were two-tailed with a confidence level of 95%.

RESULTS: Average duration of T2DM was 8.86 5.7 years, average fasting blood sugar was 201.7 40.8 mg/dL and average HbA1c was 8.36. Average duration of dyspepsia among diabetics and non-diabetics was 7.6 1.4 months and 5.5 0.3 months, respectively. Heartburn and indigestion were the commonest symptoms for both diabetics (90%, 96.7%) as well as non-diabetics (100%, 100%). Average gastroesophageal junction distance from the oral cavity was 38.9 cm. Among diabetics, histopathologically proven oesophagitis was present in 9, gastritis in 27 and chronic duodenitis in 15 patients. Gastritis of the antrum was more prevalent than that


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of the body or fundus of stomach. Average HbA1c was significantly higher (P < 0.05) in H. Pylori positive patients (7.25) than in H. Pylori negative patients (6.23). A statistically significant association existed between type 2 diabetes and antral gastritis (P < 0.05) and between type 2 diabetes and prevalence of H. Pylori infection (P < 0.05). An association between diabetes and duration of dyspepsia was statistically insignificant (P > 0.05).

CONCLUSIONS: Antral gastritis and Helicobacter pylori infection was more prevalent in type 2 diabetics than non-diabetics. H. Pylori infection was more prevalent in patients with uncontrolled diabetes (HbA1c >7). Conflict of Interest: None declared.

P184: ENDOSCOPIC DIAGNOSIS OF MELANOMA OF THE UPPER GASTROINTESTINAL TRACT Nataliya Matvienko1, Evgenii Kudryavitsky2, Ilya Perfilyev2, Ivan Karasev2, Leonid Cherkes1, Tatiana Belyaeva2, Yuriy Kuvshinov2, Guram Ungiadze2 1

Blokhin Russian Cancer Research Center, Endoscopy, and Blokhin Russian Cancer Research Center, Moscow, Russia

2

AIMS: Elaboration of endoscopic semiotics of secondary and primary melanoma of upper GIT. Correlation of macroscopic and morphological characteristics of melanoma of upper GIT by using qualifying endoscopy methods. Elaboration of macroscopic classification of upper GIT melanoma. METHODS: During the period from 2005 to 2015 there have been examined 17 patients with melanoma of the upper gastrointestinal tract (10 men and 7 women; the average age 53.8) in N.N.Blokhin Russian Cancer Research Сenter. Two patients (11.7%) had primary melanoma of esophagus, in 88.3% lesion was secondary, with primary tumor on the skin. 23.5% of patients had clinical manifestations of dysphagia and bleeding. The rest 76.5% of patients had asymptomatic lesions.

RESULTS: According to findings we have developed an endoscopic classification of upper GIT melanomic lesion: Primary tumor: 1. Metastatic 2. Of unknown primary origin 3. Primary Pigment occurrence:

1. Pigmented 2. Non-pigmented Number of foci:

1. Solitary 2. Multiple


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Macroscopic form:

1. Flat elevation 2. Miliary 3. Exophytic: Ø Plaque-like Ø Tuberous

4. Ulcered CONCLUSIONS: Melanoma is a tumor with aggressive behavior, caused by its high metastatic potential. According to world literature, metastatic foci can often be located in GIT. A primary GIT Melanoma relates to rare tumor lesions. Endoscopic Procedures play key role in detection of primary and secondary lesions. Endoscopic methods of GIT examination should necessarily be included to checkup for all patients with skin melanoma. Detection of metastases influences staging of illness with secondary lesion, first focus of metastasing was often located in GIT organs. Polymorphism of the macroscopic forms of melanoma can lead to diagnostic mistakes, most can be avoided by using up-to-date endoscopic equipment with high resolution and availability of qualifyimg methods, such as narrow-band imagine, zoom-endoscopy. Necessary sampling for histological and immunohistochemical research is key method of diagnosis verification. Conflict of Interest: None declared.

P185: THE VALUE OF AIMS65 SCORE IN PREDICTING OUTCOMES IN ACUTE UPPER GASTROINTESTINAL BLEEDING Fatima Abbas1, Abdelmounem Abdo2, Hatim Mudawi3 1

National Center for Gastroenterology and Liver Disease, Medicine, 2National Center for Gastrointestinal and Liver Diseasess, Medicine, and 3University of Khartoum, Medicine, Khartoum, Sudan

AIMS: To evaluate the newly proposed, simple risk stratification score called AIMS65 score in predicting clinical outcomes in patients with upper gastrointestinal bleeding and compare between patients with variceal and nonvariceal haemorrhage. METHODS: This is a cross sectional hospital based study conducted in Mohamed Salih Idris Gastrointestinal bleeding center Khartoum, Sudan from March to June, 2015. AIMS65 score was calculated and the outcomes (mortality, length of hospital stay, requirement for intensive care and rebleeding) studied in relation to AIMS65 score. A: albumin< 3, I: INR >1.5, M: mental state; GCS< 14, Systolic blood pressure 65 years

RESULTS: A total of 177 participants were included in this study of which 68.4% were men. The mean (SD) age was 51 (16.37) years. Variceal haemorrhage was the most common cause of upper gastrointestinal bleeding 75.7% compared to nonvariceal 24.3%. The overall mortality rate was 13%. The majority of deaths 81.8% being in those with variceal

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 haemorrhage while only 18.2% in those with nonvariceal. The length of hospital stay was greater among variceal haemorrhage patients with higher AIMS65 score. Rebleeding occured in 30.8% of variceal bleeds and in 4.5% of nonvariceal bleeds. Need for ICU admission rose with higher AIMS65 scores. There was statistically significant association between AIMS65 score and the following:death (0.003), length of hospital stay (0.002), need for ICU (0.001) but not for rebleeding (0.41).

CONCLUSIONS: The AIMS65 score is a promising simple score that is useful in predicting morbidity and mortality in upper gastrointestinal haemorrhage. Conflict of Interest: None declared.

P186: SHOULD UPPER ENDOSCOPY BE A ROUTINE PREOPERATIVE DIAGNOSTIC TOOL IN BARIATRIC PATIENTS? REVIEW OF 947 PATIENTS Bassem Abou Hussein, Ali Khammas, Ali Al Ani, Sameer Al Awadhi, Mayyasa Hussein, Mariam Sandal, Mariam Shokr, Alya Al-Mzarouei, Faisal Badri Rashid Hospital - Dubai Health Authority, Dubai, United Arab Emirates

AIMS: The preoperative use of gastroscopy for patients undergoing bariatric surgery remains controversial. We tried to evaluate the importance of gastroscopy and the possible need for rendering it a standard tool in the properative preperation of bariatric surgery. METHODS: The medical records of obese patients who underwent gastroscopy prior to bariatric surgery between January 2011 and Junte 2016 were reviewed. patients were divided into 4 groups according to the following criteria: group 0 (normal endoscopy), group 1 (abnormal findings that did not change the decision of the procedure), group 2 (abnormal findings that changed the surgical plan or postponed surgery), and group 3 (results that were an absolute contraindication to surgery).

RESULTS: 947 patients were evaluated by EGD prior to bariatric surgery. One or more lesions were identified in 77.5% of patients, with 58% having a clinically important finding. The prevalence of endoscopic findings using the classification system above was as follows: group 0 (17.28%), group 1 (26.19%), group 2 (55.99%), and group 3 (0.53%). Overall, the most common lesions identified were hiatal hernia, gastritis, positive CLO test, esophagitis, gastric ulcer, Barrett´s esophagus and esophageal cancer. CONCLUSIONS: Preoperative upper endsocopy is an important tool in preparation of bariatric patients. It helps in identifying gastric and esophageal pathologies that may necessitate preoperative treatment. Conflict of Interest: None declared.




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P187: PALLIATION OF MALIGNANT GASTRIC OUTLET OBSTRUCTION AT COUNTIES HEALTH. NOVEL USE OF FULLY COVERED OESOPHAGEAL STENTS

to endoscopic treatment. We report successful management of this condition using Radio-frequency ablation.

Ravinder Ogra, Paras Garg

RESULTS: 73-year old patient with treatment resistant GAVE who developed progressive gastric cardia and duodenal vascular ectasia during unsuccessful conventional treatment of GAVE. Between 2008 and 2013 the patient was treated with 18 sessions of Argon plasma coagulation and 4 sessions of band ligation. Tests for cirrhosis of liver and portal hypertension were negative. She became transfusion dependent and required 45 units of RBC and 8 total iron infusions over this period. She was advised to have gastric surgery when the presurgery endoscopic assessment led to discovery of the additional significant duodenal and cardia lesions. All areas were treated with radiofrequency ablation (HALO90 Ultra long catheter). Two sessions of ablative therapy has been very successful and the patient has not required Iron infusion or blood transfusion for last 10 months since the first Halo treatment. We recognise the need for further studies to investigate the efficacy of radiofrequency ablation as first line treatment of patients with GAVE and other endoscopically accessible angioectasia in the upper GI tract.

Middlemore Hospital, Gastroenterology, Auckland, New Zealand

AIMS: Endoscopically placed gastroduodenal stent placement has almost become the mainstay of palliative treatment for malignant gastric outlet obstruction and a variety of stents are used for palliation of this condition. Aim was to study efficacy of a fully covered Oesophageal stent in this situation. METHODS: Data on 71 patients who had undergone gastroduodenal stent placement at our institute (Middlemore Hospital) from 2005 to early 2016 were reviewed. Due to high rate of stent failure with the partially covered and uncovered enteral stents we have started using fully covered oesophageal stents delivered through the scope in selected cases. Data were collected for life expectancy post stenting, stent migration, tumour ingrowth/overgrowth into the stent and restenting rates with respect to type of stent used i.e. fully covered, partially covered and uncovered.

RESULTS: Out of 71, 13, 33 and 25 patients received fully covered, partially covered and uncovered stents respectively. Post-stenting median survival was 335 days with fully covered stents as compared to 162 and 57 days with partially covered and uncovered stents respectively. The rate of tumour invasion into the stent was 0%, 30.3%, 28% respectively. Stent migration was 30.8%, 3% and 8% respectively. The restenting rates were 23%, 60% and 52% respectively.

CONCLUSIONS: The traditional partially covered and uncovered gastroduodenal stents are associated with significant stent failure due to tumour invasion and this can be overcome by use of through the scope fully covered oesophageal stent. This stent was also found to result in significantly longer median survival post-stenting. This could become the first choice in a select group of patients. Conflict of Interest: None declared.

METHODS: Description of the endoscopic technique for management of this case.

CONCLUSIONS: Radio-frequency ablation can be successfully used in case of refractory GAVE. We also suggest careful endoscopic examination of the cardia and duodenum in cases of treatment resistant GAVE to exclude other angioectasia. Conflict of Interest: None declared.

P189: EFFICACY AND SAFETY OF TC-325 (HEMOSPRAY) FOR NON VARICEAL UPPER GASTROINTESTINAL BLEEDING AT MIDDLEMORE HOSPITAL: THE EARLY NEW ZEALAND EXPERIENCE Ravinder Ogra, Stephen Gerred, Hannah Giles, Luo Derek, Paul Casey, Dinesh Lal, Alasdair Patrick Middlemore Hospital, Gastroenterology, Auckland, New Zealand

AIMS: A short report on early experiences of HemosprayTM for

P188V: SUCCESSFUL MANAGEMENT OF TREATMENT RESISTANT GASTRIC ANTRAL (GAVE), CARDIA AND DUODENAL VASCULAR ECTASIA WITH RADIOFREQUENCY ABLATION Ravinder Ogra, Yeri Ahn Middlemore Hospital, Gastroenterology, Auckland, New Zealand

AIMS: Gastric antral vascular ectasia (GAVE) is an important cause of upper gastrointestinal bleeding that can be refractory

a variety of non variceal upper gastrointestinal bleeding (UGIB) at Middlemore Hospital.

METHODS: HemosprayTM was administered therapeutically as first line or rescue at the discretion of the endoscopist. All cases of UGIB requiring HemosprayTM at Middlemore Hospital were identified to the investigator who undertook analysis of electronic and hard copy notes.

RESULTS: Between October 2013 and July 2016, 36 patients were treated endoscopically with HemosprayTM. Source of bleeding was predominantly gastric in 17 and duodenal in 15, the remainder were oesophageal. The majority of lesions were peptic ulcer or post intervention (78%), with others being Mallory Weiss tear (MWT), Dieulafoy lesion, portal hypertensive


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gastropathy and post biopsy. Thirty one were actively bleeding with mostly oozing haemorrhage (75%). Twenty three patients were on antithrombotic therapy (ATT), two each on warfarin and low molecular weight heparin (LMWH) and the remainder on antiplatelet agents. HemosprayTM was administered therapeutically in all cases, as first line or rescue. Acute haemostasis was achieved in all patients, four (11%) episodes of re-bleeding occurred within 7 days, with average follow up of 16 months. There were no instances of equipment malfunction or adverse events specific to use of HemosprayTM.

CONCLUSIONS: Our early experience with HemosprayTM is very promising and there is clear role for HemosprayTM as a rescue therapy when standard methods have failed to achieve hemostasis and possibly as first line in cases of diffuse bleeding not amenable to standard interventions. However HemosprayTM is not recommended as a standalone therapy for spurting haemorrhage due to the increased frequency of rebleeding. Conflict of Interest: None declared.

P190: MASSIVE BLOOD TRANSFUSION ADMINISTRATION IN ACUTE UPPER GASTROINTESTINAL BLEEDING IS A PREDICTOR OF SIGNIFICANT MORTALITY-DATA FROM THE AUSTRALIAN AND NEW ZEALAND MASSIVE TRANSFUSION REGISTRY Shara Ket1, Dileep Mangira1, Rasa Ruseckaite2, John Oldroyd2, Zoe McQuilten2, Gregor Brown1, Peter Gibson1, Erica Wood2


Endoscopic intervention

Radiological intervention Surgery Patients failing endoscopic therapy Mortality: 24 h, 30 day, 90 day

Variceal n = 130

Peptic Ulcer n = 226

71% Band ligation, 22% Balloon tamponade 11% TIPSS 0% 28%

71% Injection or heater probe or injection and heater probe 13% Angiographic embolisation 32% 41%

8%, 34%, 38%

6%, 16%, 20%

peptic ulcer disease (gastric n = 87, duodenal n = 139). Other causes included Mallory Weiss tears (n = 8), oesophageal ulceration (n = 5), upper gastrointestinal cancer (n = 8) and other (n = 4). 36% of patients failed endoscopic management requiring balloon tamponade, angiography or surgery. Overall 90-day mortality in AUGIB was 27% (Table 1). [Table1. AUGIB intervention and mortality]

CONCLUSIONS: AUGIB requiring massive transfusion is associated with significant mortality, with a large proportion unable to be controlled by endoscopic intervention. Further studies into risk factors, optimal management (including transfusion) strategies and outcomes for these patients are required. Conflict of Interest: None declared.

1

Alfred Hospital, Department of Gastroenterology, and Monash University, Department of Epidemiology and Preventive Medicine, Melbourne, Australia 2

AIMS: Acute upper gastrointestinal bleeding (AUGIB) requiring massive transfusion is a gastroenterological emergency. Limited data are available on specific aetiologies, interventions and clinical outcomes in AUGIB. The Australian and New Zealand Massive Transfusion Registry (ANZ-MTR) contains comprehensive data from 22 hospitals on 4379 adult patients receiving massive transfusion (≥5 red blood cell units within a 4-h period) for any bleeding context. The aim of this study is to define aetiology, interventions and clinical outcomes of AUGIB receiving massive transfusion in ANZ-MTR. METHODS: Demographics, diagnosis, procedures, and mortality were extracted for 4379 ANZ-MTR events from 2011– 2016. Two gastroenterologists reviewed gastrointestinal bleeding ICD 10 codes to determine causes of critical bleeding and interventions (endoscopic, radiological, surgical).

RESULTS: AUGIB accounted for 381 cases (8.7%) of massive transfusion. Of these, 69% were male, mean age 62 (21–94) years. 34% of patients experienced variceal bleeding (oesophageal n = 119, gastric n = 11). 59% patients bled from

P191: COMPARISON ON THE EFFICACY BETWEEN PARTIALLY COVERED SELF-EXPANDABLE METAL STENT WITH ENLARGED HEAD VS UNCOVERED SELF-EXPANDABLE METAL STENT FOR PALLIATION OF GASTRIC OUTLET OBSTRUCTION Jong Jin Hyun, Jung Wan Choe, Dong-Won Lee, Seung Young Kim, Sung Woo Jung, Young Kul Jung, Ja Seol Koo, Hyung Joon Yim, Sang Woo Lee Korea University Ansan Hospital, Internal Medicine, Ansan, Republic of Korea

AIMS: Stent migration rarely occurs with uncovered SEMS (uSEMS), but tumor ingrowth is a problem. Tumor ingrowth can be expected to be prevented with covered SEMS, but migration poses a problem. If the proximal portion of the SEMS is enlarged so as to take on a funnel shape and covering material is applied at the mid-portion that is in contact with the SEMS, migration and tumor ingrowth can both be expected to be minimized. This study aimed to compare the efficacy between partially covered SEMS with enlarged head and uncovered SEMS for palliation of GOO.


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 METHODS: From July 2009 to July 2016, 48 patients underwent duodenal SEMS insertion for palliation of GOO due to inoperable or advanced malignancy at Korea University Ansan Hospital. Enlarged-head SEMS and uncovered SEMS was inserted in 24 patients each. Technical feasibility and clinical outcomes were compared between the two types of SEMS.

RESULTS: Technical success rate of enlarged-head SEMS and uSEMS was 100%(24/24) and 95.8%(23/24), respectively. Functional success rate was 91.7%(22/24) and 95.7%(22/23), respectively. Mean age of the patients was 71.7 11.2 years. The reason for GOO was progression of pancreatic cancer (n = 20), gastric cancer (n = 9), gallbladder cancer (n = 7), cholangiocarcinoma (n = 5), CBD cancer (n = 5), AoV cancer (n = 1), and duodenal cancer (n = 1). Mean survival of enlarged-head SEMS group and uSEMS groups was 98.2 days (range 19–358 days) and 80.1 days (range 11–231 days), respectively. Mean stent patency of enlarged-head SEMS group and uSEMS groups was 89.6 days (range 13–358 days) and 69.9 days(range 2– 231 days), respectively (P = 0.34). With enlarged-head SEMS, distal migration did not occur, but proximal migration was observed in 1 case. Fracturing of the enlarged-head SEMS occurred in 2 cases and tumor ingrowth through the membrane in 2 cases.


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were localized in UGIT and all of them were retrieved. Nineteen patients reported within six hours of ingestion and majority of them (84.2%) had foreign bodies within UGI tract. Those patients (62%) who reported beyond six hours, only (31.25%) had foreign bodies in UGI tract as a result the success rate of removal was only 32%.

CONCLUSIONS: Most of our patients were young females who use pins to tie their Scarf. Most common foreign body was Scarf pins followed by coins and needles. The success rate of retrieval was high in those who reported within six hours of ingestion. We recommend an early endoscopy in these patients and an alternative to use of Scarf pins preferably non metallic plastic pins. Conflict of Interest: None declared.

P193: PREDICTORS OF REBLEED AND MORTALITY IN PATIENTS WITH UPPER GI BLEED Kayalvizhi Nagarajan, Pradeep Kakkadasam Ramaswamy, Amit Yelsangikar, N.K. Anupama, Naresh Bhat Aster CMI Hospital, Department of Gastroenterology, Liver Diseases and Clinical Nutrition, Bangalore, India

CONCLUSIONS: Although distal migration was prevented by shaping the SEMS to have enlarged-head, there was no difference in stent patency between the two types of SEMS. Conflict of Interest: None declared.

P192: UNIQUE PATTERN OF FOREIGN BODY INGESTION IN KASHMIR Nisar Shah, Showkat Kadla, Asif Shah, Bilal Khan, Shabir Sheikh GMC Srinagar, Gastroenterology, Srinagar, India

AIMS: Accidental ingestion of non food products and foreign bodies is unusual especially ingestion of pins (scarf pins) and needles. We come across ingestion of these unusual foreign bodies frequently. The aim of our study was to observe, the spectrum of non food or true foreign body ingestion in our community and to see the impact of early Endoscopy to the outcome. METHODS: This prospective observational study was conducted in the department of gastroenterology, GMC Srinagar from January 2015 to January 2016. Fifty one patients with history of accidental ingestion of true foreign bodies were enrolled. Patients of all ages and both sexes were included. Those patients with structural abnormalities of gut, history of psychiatric ailment, dysphagia and bulimia and those incarcerated were excluded.

AIMS: Despite advances in management the overall mortality in patients with Upper GI Bleeding (UGIB) remains high. The aim of this study was to identify the predictors of re-bleeding and mortality in patients with UGIB. METHODS: All patients who presented to the hospital with an UGIB - within the study period from June 2014 to July 2016 were included in the study. Clinical, demographic and laboratory details were obtained. After initial resuscitation patients underwent an Upper GI endoscopy within 18 hours of hospital admission.

RESULTS: Of the 147 patients, 82% were men. Variceal bleeding (35%) and ulcer bleeding (25%) were the most common causes of UGIB. Eleven of the 147 patients (7.4%) had a rebleed, 8 patients with variceal and 3 patients with ulcer bleeding. The overall mortality rate was 10.2% (15/147 patients). Mortality was significantly higher in the variceal group (17.3%) when compared to the non-variceal group (2.1%). Mortality was seen in six out of 11 patients (54.5%, P 0.001) with rebleeding in hospital. The significant predictors of rebleeding and mortality were presence of multiple comorbidities, postural hypotension at admission, rebleeding in hospital, gastric variceal bleed, Forrest IIA or 1 peptic ulcer, and a Rockall score of ≥5 at admission. CONCLUSIONS: Presence of postural hypotension at admission, multiple comorbidities, re-bleeding in hospital and a Rockall Score of ≥5 are predictors of rebleeding and mortality. Conflict of Interest: None declared.

RESULTS: Out of fifty one patients with foreign body ingestion, 42 were ≤20 years; there were 44 females and only seven males. There were thirty eight pins, seven coins, four needles and one each Denture and a nail. Overall 26 (51%) foreign bodies


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P194: ARGON PLASMA COAGULATION RESULTS FOR THE TREATMENT OF GASTROINTESTINAL VASCULAR LESIONS riam Sabbah1,2, Asma Norsaf Bibani1,2, Nawel Bellil1,2, Me Ouakaa1,2, Dorra Trad1,2, Dalila Gargouri1,2, Hela Elloumi1,2, Jamel Kharrat1,2 1


AIMS: Argon plasma coagulation (APC) is the gold standard for the destruction of gastrointestinal vascular lesions. The aim of our study was to evaluate the efficacy and safety of argon plasma coagulation in the treatment of gastrointestinal vascular lesions. METHODS: A retrospective study (January 2012 - December 2015) including all patients with gastrointestinal vascular lesions treated by APC was performed. Treatment was used at a power ranging from 40 to 70 W and a flow rate of 0.6 to 1.2 L/min depending on the location of lesions. A successful treatment was defined by control of gastrointestinal bleeding and / or absence of recurrence of anemia.

RESULTS: 30 patients were included. Comorbidities were noted in 13 patients (44%): 10 patients with heart disease and 3 patients with end stage renal disease requiring hemodialysis. Vascular lesions were revealed by externalized bleeding in 35% of cases (n = 10) and iron deficiency anemia in 65% of cases (n = 20). Vascular lesions observed in our cohort were angiodysplasia (n = 28) and gastric antral vascular ectasia (n = 2). Forty sessions of APC were performed (mean 1.33 sessions per patient). A bleeding control was obtained in all patients treated with APC without recurrence of bleeding. In patients treated for iron deficiency anemia, the outcome was favorable with no necessary repeated transfusions in 80% of cases (n = 16). A recurrence of anemia was observed in 8 patients (26%). Surgical treatment was necessary in two patients due to small bowel bleeding angiodysplasias. No complications of endoscopic treatment were observed in our study. CONCLUSIONS: Argon plasma coagulation is a simple, safe and effective technique for the management of bleeding gastrointestinal vascular lesions. It reduced the need for surgery in patients with frequent associated comorbidities. Conflict of Interest: None declared.

AIMS: Gastric polyps are a heterogeneous group and are most often benign (>85%). Upper endoscopy has a dual interest in both diagnostic and therapeutic management of these lesions. The aim of our study was to investigate the endoscopic gastric polyps related to their histological type and to specify their endoscopic management and its complications. METHODS: A single-center retrospective study including all patients who underwent upper endoscopy showing gastric polyps between January 2011 and December 2015 was performed. The parameters studied were age, gender, family and personal history of gastrointestinal neoplasia, symptoms, endoscopic parameters, results and complications of polypectomy, as well as histological results.

RESULTS: 42 patients were included (average age 56.8 years [23–90], sex ratio = 1). Family history of gastrointestinal neoplasia were found in 6 cases (14.2%). gastric cancer in 3 cases, and familial adenomatous polyposis in 3 cases. Twelve patients received long-term PPIs. Indications of upper endoscopy were dominated by epigastric pain (78.6%) followed by vomiting (23.8%). Polyps were unique in the majority of cases (78.8%). 83.3% of polyps had a size < 1 cm (mean size 6.8 mm) and were pediculated in 59.5%. Endoscopic resection was performed by using snare (59.4%), by biopsy (33.3%) and mucosal resection in 3 patients. Concerning complications, bleeding was observed in 4 cases, necessitating the use of clips. No cases of perforation were noted. Histological examination revealed benign polyps in 95.2% of cases: 15 adenomas, 15 cysto-glandular, 7 hyperplastic and one xanthoma. Stromal tumor and a carcinoid tumor were found in one patient each. CONCLUSIONS: All gastric polyps even if they seem endoscopically benign should be subject to a histopathological examination in order to detect malignant lesions and those suitable for adequate treatment or special monitoring. Conflict of Interest: None declared.

P196: SAFETY AND FEASIBILITY OF EUS-GUIDED FIDUCIAL PLACEMENT FOR IMAGE-GUIDED RADIATION THERAPY IN PANCREATIC CANCER - A SYSTEMATIC REVIEW Anwar Dudekaula1, Guru Trikudanathan2, Martin Freeman2, Nalini Guda3 1

University of Pittsburgh Medical Center, Pittsburgh, University of Minnesota, Gastroenterology, Minneapolis, and 3Aurora St.Luke’s Medical Center, Gastroenterology, Milwaukee, USA 2

P195: ENDOSCOPIC MANAGEMENT OF GASTRIC POLYPS riam Sabbah1,2, Asma Norsaf Bibani1,2, Asma Sabbek1,2, Me Ouakaa1,2, Dorra Trad1,2, Dalila Gargouri1,2, Hela Elloumi1,2, Jamel Kharrat1,2 1


AIMS: Stereotactic body radiotherapy (SBRT) for locally advanced pancreatic cancer allows precise spatial- targeting of tumor using real-time tracking of radiopaque fiducial marker. EUS enables precise and close visualization of structures in abdomen and within proximity of GI tract for placement of fiducial markers.


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 The aim of this study is to evaluate the safety and feasibility of EUS-guided fiducial markers placed for SBRT in pancreatic cancer by pooling results of all available studies.

METHODS: A systematic search was performed from five electronic databases for studies between January 1998 to August 2016 per PRISMA guidelines. Only studies in English language involving EUS guided placement of fiducial markers for pancreatic cancer were included. Outcomes of interest include technical success and failure, fiducial migration rate and postprocedural complications.

RESULTS: A total of 14 retrospective studies involving 476


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(80) of patients and was predicted by female gender (P = 0.001) and the absence of heartburn (P = 0.004).

CONCLUSIONS: EGD is a useful diagnostic tool for initial evaluation of dysphagia. Conflict of Interest: None declared.

P198: DESCRIPTIVE STUDY OF UPPER GASTROINTESTINAL BLEEDING Than Than Aye

patients (mean age 65.1 10.4 years, 56% males) were included in our study. Majority of studies were from USA (86%). Mean number of fiducials used per patient were 2.8. Pooled technical success in 97% (range 87–100%) and failure in 10% (range 0–16%) were estimated. Spontaneous fiducial migration was noted in 7% of patients (range 0%-22%) and 5% of fiducials (range 0–13%). 19, 22-gauge and 19 & 22 gauge EUSFNA needles were used in 62%, 23% and 15% of studies. Overall, adverse events were reported in 3.8 % of patients.

AIMS: Acute upper gastrointestinal bleeding (UGIB) is still common and comprise the major cause of hospital admissions. Timely endoscopic therapy can save life and avoid surgery. This study to assess the clinical characteristics, endoscopic accuracy, treatment efficiency and clinical outcome of patients admitted to the endoscopy unit with UGIB.

CONCLUSIONS: EUS-guided fiducial placement for SBRT for

METHODS: A retrospective cases analysis of all patients who

pancreatic malignancies is technically safe, and feasible with minimal procedural complications and a low fiducial migrationrate. Conflict of Interest: None declared.

P197: RETROSPECTIVE ANALYSIS OF ENDOSCOPIC FINDINGS IN PATIENTS PRESENTING WITH DYSPHAGIA V.K. Dixit, Shivam Sachan, S.K. Shukla IMS, BHU, Gastroenterology, Varanasi, India

AIMS: To analyse the initial endoscopic findings in patients presenting with dysphagia. METHODS: This is a retrospective analysis of patients who underwent EGD for dysphagia and was retrieved from the database of endoscopy unit. Patients who had undergone prior esophageal evaluation, or who had a history of prior upper GI pathology were excluded.

RESULTS: A total of 200 patients with dysphagia (mean age 51.3 years, M:F 3:2) were analyzed. Abnormal findings at EGD were found in 60% (120) of the patients, and a significant pathology was seen in 52% (104). Male gender (P = 0.0001), heartburn (P = 0.0001), and odynophagia (P = 0.0001) were associated with the presence of major pathology. Malignant strictures were found in 29.1% (35) of patients and was associated with male gender (P = 0.001), age (P = 0.01), and weight loss (P = 0.03). Benign strictures were found in 16.6% (20), GERD was found in 38.3% (46) of patients, Dilated esophagus was seen in 6.6% (8) patients, other findings were seen in 9.1% (11) of patients. The esophagus was normal in 40%

University of Medicine 2 Yangon, Department of Gastorenterology, Yangon, Myanmar

underwent endoscopy for upper gastrointestinal bleeding during a period of 3 years (2013 to 2015).

RESULTS: In total 1950 patients, most patients were male 79.5% with the age ranged from 3 to 97 years and mean age was 50.1 year. The accurate causes of UGIB were identified in 97% of cases. Esophageal varices were the most frequent causes 36.9%, followed by peptic ulcer in 30%, erosive gastritis in 7.3%, portal hypertensive gastropathy in 6.7%, Ca stomach 3.2%, Gastric varices in 3 %, Mallory Weiss tear in 3% respectively. Need therapeutic interventions in 42% of UGIB. These were endoscopic variceal ligation in 635 patients, N butyl 2 histoacryalate injection in 58 cases of gastric varices and 2 cases of duodenal varices, endoscopic intervention in 93 cases of peptic ulcer bleeding and almost all cases of Dieulafoy bleeding. Permanent hemostasis was achieved at the first endoscopic intervention in 97.2% of the patients with variceal and nonvariceal bleeding. Re-bleeding was reported in 2.8% of the patients. Overall mortality rate was 0.6% correlated with previous liver disease and old age with co-morbidity. Only one patient underwent emergency surgery because of the uncontrolled posterior duodenal ulcer bleeding despite endoscopic epinephrine injection and heater probe. CONCLUSIONS: The source of UGIB could be identified with endoscopy in most cases. Esophageal varices and peptic ulcer remain the leading causes of acute UGIB. Therapeutic endoscopy proved to be an efficient tool in the management of UGIB. Application of Various endoscopic modalities improved the outcome. Conflict of Interest: None declared.


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P199: THE USE OF SELF-EXPANDING FULLY COVERED METAL STENT FOR CONTROL OF REFRACTORY VARICEAL HAEMORRHAGE Mahesh Goenka1, Chinmay Bera1, Vijay Rai1, Indrajit TiwarI1, Usha Goenka2 1 Apollo Gleneagles Hospitals, Institute of Gastrosciences, and 2Apollo Gleneagles Hospitals, Department of Clinical Imaging and Interventional Radiology, Kolkata, India

AIMS: Balloon tamponade or Transjugular Intrahepatic portosystemic shunt is mainstay of therapy for refractory esophageal variceal bleeding (EVB). Self expandable esophageal covered metal stent (SX-ELLA Danis; Ella-CS, Hradec Kralove, Czech Republic) is an effective and safer alternative to balloon tamponade for control of EVB in patients with treatment failures or bleeding from ulcers following endotherapy. METHODS: Between November 2011 and May 2016, esophageal SEMS were implanted in 12 patients (11 men, one woman; Mean age 55; Range 27 to 72) with refractory EVB after stabilization with pharmacologic therapy and packed cell transfusion.

RESULTS: Twelve Child class- C cirrhotic patients (MELD: 20 6; mean SD) with refractory EVB (post variceal ligation ulcer-8; uncontrolled bleeding-4) were managed with covered esophageal SEMS. Stents were successfully placed in all patients. In ten patients SEMS were placed in endoscopy suite under fluoroscopic control and two at bedside. Stents were left in place in 7 to 30 days. No acute haemorrhage or local complication was noted on stent retrieval in 8 patients. Thirty days mortality was noted in 4 patients due to uncontrolled sepsis and worsening liver functions. However, none of the patients died due to uncontrolled bleeding.

CONCLUSIONS: In this prospective study, implantation of covered esophageal stent was found to be safe and effective to control refractory EVB. Conflict of Interest: None declared.

P200: CURRENT ETIOLOGICAL AND ENDOSCOPIC PROFILE OF UPPER GASTROINTESTINAL BLEED IN INDIA - A LARGE COHORT STUDY FROM TERTIARY CARE GI CENTRE Hrushikesh Chaudhari, Jahangeer Basha, Rajesh Gupta, Manu Tandan, D. Nageshwar Reddy Asian Institute of Gastroenterology, Hyderabad, India

AIMS: Over the last few decades, data from developed countries have shown that the epidemiology, aetiology and outcome of upper gastrointestinal bleed (UGIB) has changed. However, there is limited data from India. The present study is to evaluate the current spectrum of UGIB in India.

METHODS: Six hundered and foury-one patients (Mean age49.9 years; 82.3% males) with UGIB were included from April 2011 to March 2013. A complete clinical assessment and relevant laboratory investigations were done. All patients underwent upper gastrointestinal endoscopy to evaluate the cause of bleed and endotherapy was done wherever indicated. The need for additional therapeutic interventions like Angiography and Surgery were also recorded.

RESULTS: Melena was the most common presenting feature (75.5 %). Esophageal varices were the most frequent cause of UGIB (35.38 %) followed by peptic ulcers 16.93% (duodenal ulcer in 8.79 %, gastric ulcer in 5.70 %), GAVE (6%), Hemosuccuspancreaticus (6%), Erosions (5.7%), Mallory-Weiss tear (4.89%), Iatrogenic (4%), Malignacy (3.58%), Dieulafoy’s lesion (1.79%). Among Variceal UGIB, CLD was present in 86.9%, EHPVO in 12.7%, NCPF 1%. And Endotherapy was required in all patients. Among Non variceal bleed Endotherapy was required in 56.73% while 43.27% managed conservatively. Rebleed rate was significantly lower with combination therapy as compared to single therapy (4.43% vs 36.11%). Therapeutic Angiography required in 4.21% and 0.67% underwent surgery. Mortality rates for variceal and peptic ulcers bleed were 21.74% & 7.69 % respectively. CONCLUSIONS: Variceal bleed is the most common cause UGIB and responsible for the higher mortality. Combination endotherapy is better than monothaerapy in non variceal UGI bleed. Conflict of Interest: None declared.

P201: ACOUSTIC RADIATION FORCE IMPULSE ELASTOGRAPHY OF LIVER CAN PREDICT THE PRESENCE OF CLINICALLY SIGNIFICANT ESOPHAGEAL VARICES Mahesh Goenka1, Md Nadeem Parvez1, Chinmay Bera1, Usha Goenka2 1

Apollo Gleneagles Hospitals, Institute of Gastrosciences, and 2Apollo Gleneagles Hospitals, Department of Clinical Imaging and Interventional Radiology, Kolkata, India

AIMS: Presence of varices is a definite sign of portal hypertension. Periodic endoscopic screening for oesophageal varices is recommended in patients with chronic liver disease to look for the development of clinically significant varices. Noninvasive test such as Acoustic Radiation Force Impulse (ARFI) elastography can exclude the presence of clinically significant varices. METHODS: Total 114 patients with liver disease (inconclusive of cirrhosis on ultrasonography) underwent ARFI elastography and endoscopy at the same time period. The relationship between the presence of oesophageal varices and liver stiffness measurement by ARFI was assessed.

RESULTS: One hundred and fourteen patients (Mean age 44 13, M/F = 78/36) with liver diseases (Cryptogenic= 39,


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 Hepatitis B = 37, Non-alcoholic fatty liver disease= 32, Autoimmune= 3, Hepatitis C = 1 and others= 2) underwent ARFI elastography. The mean ARFI (10 measurements per patients) values of our study populations was 2.07 0.87 m/sec. Varices were found in 14% patients. Clinically significant varices (grade ≥2) were seen in 3.5% patients. The ARFI values were significantly higher in patients with clinically significant varices as compared to patients without significant varices (3.63 0.30 vs 2.01 0.08, P < 0.001). Liver stiffness was positively correlated to the grade of oesophageal varices (r = 0.78, P < 0.043). AUROC values of liver stiffness measurement were 0.84 (95% CI: 0.78–0.90) for the presence of oesophageal varices and 0.83 (0.76–0.89) for large varices. ARFI value of < 2.0 m/sec was highly predictive of the absence of large oesophageal varices.


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4 leiomyoma, 2 GIST, 2 dysplastic Lipoma, three inflammatory fibroid polyp, one myofibroblastic tumour and one hyperplastic polyp. Fourteen patients had completed surveillance endoscopy (SE) without an endoscopic and histological recurrence (Median follow up 24 months). Three patients are pending SE. The four patients with deep MP involvement were referred for surgery.

CONCLUSIONS: ESD for selected UGI SMT is an effective treatment. Long term endoscopic follow up confirmed the absence of recurrence endoscopically and histologically. MP involvement cannot be reliably excluded by prior EUS. This technique should be considered for UGI SMT lesions without MP involvement in experienced centres. Conflict of Interest: None declared.

CONCLUSIONS: Liver stiffness measured by ARFI elastography may non-invasively predict the presence or absence of clinically significant esophageal varices. Conflict of Interest: None declared.

P202: ENDOSCOPIC SUBMUCOSAL DISSECTION FOR UPPER GI SUBMUCOSAL TUMOURS Halim Awadie1, David J. Tate1, Amir Klein1, Lobke Desomer1, Michael Ma1, Steven J. Heitman1, Nicholas G. Burgess1,2, Eric Y. T. Lee1, Vu Kwan1, Michael Bourke1,2 1

Westmead Hospital, Gastroenterology and Hepatology Department, Westmead, and 2University of Sydney, Sydney, Australia

P203: CLINICAL PROFILE OF FOREIGN BODY IN UPPER DIGESTIVE TRACT IN SOUTH INDIAN TERTIARY CARE HOSPITAL Ashfaq Ahmed, Waseem Raja, Saji Varghese, Sandheep Janardanan, Mary George, Sameer Hussain, Benoy Sebastian, Sunil Mathai Medical Trust Hospital, Gastroenterology and Hepatology, Kochi, India

AIMS: To present the cases of foreign body in upper digestive tract encountered in Department of Gastroenterology, Medical Trust Hospital, Kochi, Kerala, India. METHODS: The study includes all the patients presented with

AIMS: Submucosal tumours (SMT) in the upper gastrointestinal tract (UGI) impose diagnostic and therapeutic challenges. They may have malignant potential and endoscopic ultrasound (EUS) guided diagnosis is often inaccurate. Endoscopic submucosal dissection (ESD) offers the possibility of complete resection and definitive histological diagnosis. Our aim was to analyse the data from our referral centre.

METHODS: A prospectively collected ESD database was analysed to identify patients with SMT of the UGI. All lesions underwent EUS assessment with the aim to exclude muscularis propria (MP- muscular layer beneath the mucosa) involvement prior to resection.

RESULTS: Over 42 months, 24 ESDs for SMT lesions were performed. The mean age was 62 years with 13 male patients (54%). Median lesion size was 20 mm. Nineteen patients (76%) had completely resected tumours. Four patients (18%) had involvement of the MP, and one patient had MP injury which precluded complete resection. Three of five lesions of the incompletely ESD procedures were in the proximal body of the stomach, however only one lesion of the completely resected lesions was in the proximal body (P –0.0002). Otherwise, there were no significant differences between the patients and lesions characteristics. The histology of the SMT lesions were 7 NET, 4 Granular cell tumours,

history of foreign body in upper digestive tract to department of gastroenterology from April 2015 to May 2016. All patients underwent Endoscopic procedure.

RESULTS: In this study a total of 110 patients were presented with history of foreign body in upper digestive tract. Foreign body impaction was more prevalent in males (65) compared to females (45). Common age group with foreign body ingestion was in 40–60 years (40.9%). Fish bone (43.6%) was frequently encountered foreign body in Upper digestive tract. Upper Esophagus was common site of foreign body impaction. In Children’s most common foreign body seen was coin. CONCLUSIONS: Endoscopic management for foreign body in upper digestive tract is easier and reduces the serious complications. Conflict of Interest: None declared.


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P204: LONG TERM OUTCOMES OF HIGH GRADE UPPER GASTROINTESTINAL TRACT INJURY FOLLOWING ACUTE CORROSIVE INGESTION (ACI) Sudipta Dhar Chowdhury, Kumar C. Bharath, Soumya Kanti Ghatak, Devarakonda Sreekar, Reuben Thomas Kurien, A.J. Joseph Christian Medical College, Gastroenterology, Vellore, India

AIMS: The study is aimed at assessing the long term outcomes of high grade (Zargar’s grade ≥Grade 2A) injury of upper gastrointestinal tract following acute corrosive ingestion (ACI). METHODS: This was a prospective follow up study which included patients who presented to our hospital between January 2008 to December 2014 with ACI. All patients were managed as per standard protocol. In this study we included patients ≥15 years with high grade (Zargar’s grade ≥Grade 2A) corrosive induced injury of upper gastrointestinal tract. Patients in whom gastroscopy could not be done or who were primarily managed at another hospital were excluded.

RESULTS: In all 82 patients were included, 53% were females and mean age was 36.5 15.5 years. Intent of ACI was suicidal in 70%. Of those included 11 patients were lost to follow up. The median follow-up period was 31 months (2–72) during which 12 (16.9%) patients expired (73% related to ACI). Amongst the 59 patients that are alive, 16 (27 %) are symptomatic, with dysphagia 12 (20 %), regurgitation 5 (6 %), and weight loss 6 were noted in 21 (36 %). The site of stricture was esophageal 11 (53 %), stomach 8 (38 %) and combined in 2 (9%). Esophageal stricture was seen in all with Grade IIIB esophageal injury, 27% with Grade IIIA injury and 19% with Grade IIB injury. None of the patients with Grade IIA injury developed stricture. Stricture in stomach developed in 25% patients with Grade IIIB gastric injury and Grade IIIA injury, 10%with IIB injury and 20% with IIA injury. CONCLUSIONS: Acute corrosive ingestion is associated with significant morbidity and mortality. Higher grade of injury is associated with worse outcomes. Conflict of Interest: None declared.

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 AIMS: Endoscopy in the very elderly is generally considered risk prone. Centenarians are people who are ≥100 years of age. Little is known about endoscopy in the centenarians. This retrospective study aimed to explore this. METHODS: A retrospective study analysing endoscopy in centenarians presenting to a University Hospital from 01/2005 to 01/2015 was undertaken. Endoscopy reports were retrieved from the Hospital’s Endoscopy Reporting tool and patients’ details were confirmed using the Trust´s patient database.

RESULTS: 11 procedures (7 Gastroscopies, 3 sigmoidoscopies and 1 Colonoscopy) were undertaken in 10 patients (4 male and 6 female). Age: 101 to 119 years. Mean 105.2 years. 7 (Caucasians), 2 (Indians) and 1 (Afro-Caribbean). 72 % (urgent basis). 70 % (inpatients) and majority were undertaken by Consultants (82%). Indications included Dysphagia (36.3%), Melena (27.2%), Rectal Bleeding (27.2%) and previous Cancer (9%). Procedural yield (81.8%) and endoscopic intervention performed in 2 cases (Duodenal ulcer injected with adrenaline and hemorrhoids banded). 2 procedures were performed under sedation (midazolam). 100% completion rate without immediate complications. CONCLUSIONS: To the best of the author’s knowledge this is the only study analysing endoscopic practice in centenarians. While the sample size is small it demonstrates that endoscopy can be performed safely and diagnostic yield is high. A patients’ age should not be the sole factor when deciding suitability for endoscopic procedures. Larger studies are required to gain a better understanding of endoscopic suitability for patients in this age group. Conflict of Interest: None declared.

P206: ENDOSCOPY IN THE DIAGNOSTIC AND REMOVING OF FOREIGN BODIES IN THE ESOPHAGUS Mikhail Korolev, Leonid Fedotov, Alexander Ogloblin, Maria Antipova Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russia

18.02.2017 POSTER AREA CLINICAL ENDOSCOPIC PRACTICE. OUTCOMES P205: ENDOSCOPY IN THE CENTENARIANS: IS IT WORTH THE TROUBLE? S Budihal1, D Budihal2 1 NIHR Nottingham Digestive Diseases Biomedical Research Unit, Department of Gastroenterology, Nottingham, and 2 University Hospital Wales, Directorate of Clinical Gerontology, Cardiff, UK

AIMS: Show the advantages and possibilities of endoscopic techniques in patients with foreign bodies of the esophagus. METHODS: From 1996 to 2015 6736 patients with foreign bodies of the upper GI tract were admitted to our hospital. A foreign body in the esophagus diagnosed in 87.5 % cases. The reasons for fixation of foreign body are: the configuration and size of the foreign body is 65 %, anatomical narrowing and esophageal diseases 35%. Endoscopically removed 99.7% of foreign bodies. 37 patients were admitted with symptoms of esophageal perforation. Time from the perforation ranged from 1 h to 6 days. In 3 patients with mental illness the timing of perforation is still unknown. The reasons of esophageal perforation were: a foreign body with sharp edges (10%), long-standing foreign bodies (8%), attempt of the patient to


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 push the foreign body (76%), attempts to extract a foreign body in various medical institutions, iatrogenic perforation of the esophagus by endoscope (4%), self-introduction of a foreign body to the esophagus (patients with psychiatric diseases - 2%). For diagnosis were used endoscopy in combination with x-ray, radiopaque, CT. Endoscopic examination and removing were performed in the operating room, strictly under anesthesia and CO2.

RESULTS: From 33 patients with esophageal perforation, combined surgical and endoscopic treatment were performed for 20 patients, surgery - 10 patients, 7 patients underwent endoscopic clipping of perforation. There were 2 fatal outcome, causes of which were arrosive bleeding and mediastinitis. CONCLUSIONS: Patients with suspected foreign body in upper GI tract belong to the emergency group and require urgent endoscopy in a multidisciplinary hospital. Endoscopy in patients with complicated foreign bodies of the upper GI tract demand on high qualification of doctors and presence of all necessary equipment. Modern endoscopy allows to cure the perforation of the esophagus in case of early admission to hospital from the moment of perforation. Conflict of Interest: None declared.


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RESULTS: In DPF group, the mean intake reached 2718 346 calories on day 21. In EPF group, a total duodenal tube intake of 3120 306 calories was achieved by post burn day 14 and was maintained throughout the study period. We found a more rapid increase in the mean magnesium concentrations with statistically significant difference (P = 0.049) at day 4 in the EPF group compared to the DPF group. There was a more pronounced ascent in platelet counts on day 14 in the EPF group compared to the DPF group (431.40 162.92 vs 212.88 161.08 x 103/μl, P = 0.037). CONCLUSIONS: EPF in seriously burned patients allows the provision of the calculated caloric needs. It may also serve to minimize magnesium malabsorption which causes thrombocytopenia. Conflict of Interest: None declared.

P208: OUTCOME OF ERCP FOR PATIENTS WITH TRAUMATIC PANCREATIC DUCTAL LEAK Tarun George1, Rabindranath Eswaran2, Kini Ratnakar1, Pugazhendhi Thangavelu1, Kani Sheik Muhamed3, Premkumar Karunakaran3 1

P207: IS EARLY ENDOSCOPIC REPLACEMENT OF POST-PYLORIC FEEDING TUBES BENEFICIAL IN SERIOUSLY BURN PATIENTS? Jung-Chun Lin, Yu-Chen Tseng, Bao-Chung Chen, Yu-Lueng Shih, Wei-Kuo Chang, Tsai-Yuan Hsieh Tri-Service General Hospital, National Defense Medical Center, Division of Gastroenterology, Department of Internal Medicine, Taipei, Taiwan, China

AIMS: In previous studies, early enteral nutrition improved the outcome in patients with burn injury, though most of these studies defined “early” as nasogastric feeding performed within 24 h after admission. Post-pyloric tube feeding is a valuable therapeutic option for critically major burn patients with possible delayed gastric emptying. However, the question of how early post-pyloric feeding can be initiated to prove more beneficial to the patient has not yet been examined. We compared the results of early initiation vs postponed postpyloric feeding in seriously burned patients. METHODS: At an urban, tertiary care teaching hospital during an mass casualty incident event that occurred on June 27, 2015, we conducted a retrospective analysis of data from 13 patients with seriously burned injury who received post-pyloric feeding after admission. Of these 13 patients, 5 patients underwent early post-pyloric feeding (EPF) and 8 patients underwent delayed post-pyloric feeding (DPF). Patients in the two groups were comparable with regard to admission criteria. The postpyloric feeding tubes were placed with endoscopy-assisted “drag and pull” technique.

Madras Medical College, Institute of Medical Gastroenterology, 2Madras Medical College, Medical Gatroenterology, and 3Madras Medical College, Chennai, India

AIMS: To study the outcome of Endoscopic Retrograde Cholangiopancreatography (ERCP) in patients with traumatic pancreatic ductal leak. METHODS: A retrospective review of patient data from a tertiary care centre in South India was done. Total of 4 cases were analysed out of which one case was post-surgical pancreatic ductal leak and the remaining 3 cases were pancreatic duct injury due to blunt injury abdomen. Patients relevant history, examination findings, MRI/MRCP, and endoscopic retrograde cholangiography images were noted. Details of the procedure and post procedural complications were also analysed.

RESULTS: Case 1–56 year old female underwent subtotal colectomy, splenectomy, distal pancreatectomy for splenic flexure growth. Post surgery developed leak in the tail with pancreatico-cutaneous fistula. ERP confirmed the leak and pancreatic stenting was done after which there was a complete resolution of symptoms. Case 2–61 year male had blunt injury abdomen following which developed acute necrotising pancreatitis for which pancreatic necrosectomy was done with external drainage for peripancreatic fluid collection in private hospital. Patient had 700 mL/day of collection from external drain with fluid amylase and lipase grossly elevated. Pancreatic duct (PD) stenting done (Site of MPD leak - Head), patients external drain progressively reduced and was later removed. Case 3–28 year old male sustained blunt injury abdomen, developed complete transection of main pancreatic duct at the


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level of neck with large pseudocyst anterior to body of pancreas. PD stent placed across the leak. Post procedure daily pigtail drainage progressively reduced and was later removed. Case 4 13 year male had blunt injury abdomen following which developed acute pancreatitis with large pseudocyst communicating with MPD at the neck region. ERCP failed hence managed with percutaneous pigtail drainage which resulted in marked reduction in cyst size.

CONCLUSIONS: The yield of GI endoscopy in patients of CUP

CONCLUSIONS: Pancreatic stenting is useful in traumatic

P210: USEFULNESS OF SCORING SYSTEMS IN PREDICTING REBLEED AND PROGNOSIS IN UGIB PATIENTS

pancratic leak and can avoid unnecessary surgery. Conflict of Interest: None declared.

P209: YIELD OF ESOPHAGOGASTRODUODENOSCOPY AND COLONOSCOPY IN CANCER OF UNKNOWN PRIMARY: A PROSPECTIVE SINGLE CENTRE STUDY

was 14%. There was no significant association between clinical, radiological or histological features/IHC and the presence of GI primary on endoscopy. Prospective cost effectiveness studies are warranted. Conflict of Interest: None declared.

Amol S Dahale, Ajay Kumar, Sanjeev Sachdeva, Siddharth Srivastav, Shivakumar Varakanahall, A.S. Puri GB Pant Institute of Postgraduate Medical Education and Research, Gastroenterology, New Delhi, India

Mukund Virpariya, Prachi Patil, Shaesta Mehta, Jasmeet Singh Dhingra, Pravir Gambhire

AIMS: We aim to study usefulness of Blatchford-Glassgow (BG) and AIMS 65 scoring system in UGIB patients to predict outcome of bleed in Indian setup.

Tata Memorial Hospital, Department of Digestive Disease and Clinical Nutrition, Mumbai, India

METHODS: All patients visited to G B Pant Institute of

AIMS: Esophagogastroduodenoscopy (EGD) and colonoscopy are frequently used in the workup of patients with cancer of unknown primary (CUP). Few prospective studies have evaluated their use in CUP. Our aim was to prospectively correlate clinical, radiological and serological markers with the presence of a primary lesion on endoscopy in patients with CUP. METHODS: 183 consecutive patients with CUP referred for endoscopy were recruited over 12 months at Tata Memorial Hospital, Mumbai after ethics committee approval. They underwent 250 endoscopies (154 EGD & 96 colonoscopy). Clinical details and investigations were noted. Endoscopy was performed by gastroenterologist with standard video endoscopes after standard preparation as applicable. Data was entered and analysed using SPSS v.21.

RESULTS: The mean age was 49.5 years (range 18–80 years). 77% patients were female. 86 % had gastrointestinal (GI) symptoms, commonest being abdomen pain (72%). Elevated CEA, CA 19.9, CA 125 and AFP were seen in 92, 84, 102 and 5 patients respectively. The predominant metastatic site was adnexal mass (54%) followed by peritoneum (53%), lymph nodes (28%) and liver (24%)0.88% tumors were adenocarcinoma. Endoscopy was normal in 146 (58%). On 39 (15%) endoscopies, tumorous lesions were seen (25-gastric, 14- colorectal) of which biopsy confirmed adenocarcinoma in 36 (14%). There was no significant association between the abdominal symptoms or abnormal tumour marker and presence of a GI primary on endoscopy (P > 0.05). Immunohistochemistry (IHC) was performed in 57% patients. CK7 + / CK20- and CK20 + /CDX2 + pattern did not point toward upper GI and colorectal primary respectively (P value >0.05). Isolated CK20 and CDX2/ CK7 positivity was suggestive for primary in colorectal and stomach respectively (P value < 0.05).

postgraduate education and research with UGIB from December 2014 to July 2015 prospectively included in study. All patients were treated as per standard protocol for UGIB BG and AIMS 65 scores were calculated. All patients were followed for 30 days. Outcome noted as rebleed or death.

RESULTS: Total 92 patients evaluated as UGIB, 19 were excluded after evaluation. Total 73 patients followed and data analyzed. Mean age of patients was- 43 year 17.68 year (range 8–80). Male (n–51) to female (n–22) ratio was 2.42. Portal HTN related cause was bleed in 58 (79.5%) patients. Non variceal bleed seen in 14 patients. Total 9 patient has rebleed. Total 5 patients died 4 in variceal group and 1 in nonvariceal (P –0.000). Sixty patients (82.2%) experienced 1 or more components of the composite endpoint: 5 died (6.8%), 9 rebled (12.20%), 58 required endoscopic therapy (79.5%), 2 required radiologic intervention (2.73%), and 4 required surgical intervention (5.47%). The AIMS65 score and the GB score both had low AUROCs for rebleeding (0.31 [95% CI- 0.09–0.53] and 0.36 [95% CI–0.20–0.51], respectively). However, the GB score was superior to the AIMS65 for predicting the need of packed red blood cell (PRBC) transfusions (0.79 [95% CI- 0.64–0.85] and 0.66 [range 0.53–0.79], respectively. For AIMS65 scores of 1, 2, 3, 4, and 5, mortality was 6.25%, 5%, 20%, and 50%, respectively. The AUROC for AIMS65 score predicting mortality was 0.84 (95% CI 0.76–1.00). The AIMS65 score was superior to GBRS for predicting mortality (AUROC, 0.84 vs 0.70). CONCLUSIONS: AIMS 65 and GB scores predict poor prognosis but poor in predicting rebleed. Conflict of Interest: None declared.



P211V: TRANSESOPHAGEAL NECROSECTOMY OF RETROPHARYNGEAL ABSCESS - A NOVEL ENDOSCOPIC APPROACH Nitin Pai Ruby Hall Clinic, Gastroenterology, Pune, India

AIMS: Retropharyngeal abscess often require surgical drainage. We present a case of delayed presentation of retropharyngeal abcess treated successfully endoscopically. METHODS: 65 year Diabetic male presented with 3 weeks symptoms of Odynophagia, dysphagia, cough, fever and significant weight loss H/O fishbone impaction 2 weeks prior to symtoms appearing. On examination he was Febrile, sick elderly male. Had Tachycardia. Bilateral chest revealed crepts. Raised counts 21000 P90L7. BSL 250 mg/dL fasting. BUN 104 Creatinine 2.4. XRC normal. CT thorax revealed a pus filled retropharyngeal abcess with air within

RESULTS: The endoscopy revealed a transverse impaction of fish bone with a large cavity communicating with upper esopahgus with blind sealed off fistula on opposite wall. Transesophageal necrosectomy was done with soda bicarb washes and a naso biliary drain was placed for irrigation RT was placed for feeding Antibiotics were given as per culture sensitivity. The fistula healed completely in due course.

CONCLUSIONS: Delayed presentation of retropharyngeal abscess is diifficult problem in elderly Endoscopic necrosectomy with nasobiliary drain placement is an effective treatment option is such individuals. Conflict of Interest: None declared.

P212: EGD IN UNEXPLAINED IRON DEFICIENCY ANEMIA: CROSS SECTIONAL PROSPECTIVE STUDY Gaurav Garg, Vinod Kumar Dixit, Sunit Kumar Shukla, Sudhir Kumar Singh, Shivam Sachan, Patients Having Unexplained Iron Deficiecy Anemia IMS BHU, Gastroenterology, Varanasi, India

AIMS: Iron deficiency anemia is prevalent cause of anemia both in male and Female. We planned a study to determine the prevalence of gastric and duodenal diseases among patients with unexplained IDA that underwent to UGIE and the value of endoscopic alterations in selecting patients for biopsy.


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and excluded for GI bleeding lesions were submitted to UGIE with a standard protocol of biopsies of the fundus, antrum and duodenum between Jan 2016 to July 2016 in Department of Gastroenterology, IMS BHU Varanasi.

RESULTS: 8 (16%) out of 50 pts that had normal mucosa at endoscopy had Coeliac Disease (CD) on histology.318 pts had abnormal endoscopy findings in form of Antral Gastritis 132 (41.50%), Fundal/Corporal Gastritis 68 (21.38%), Pangastritis 16 (5.03%), Antral ulcer12 (3.77%), Live worm 32 (10.06%) Ulceroinfiltrative Growth 28 (8.80%), Scalloping and nodularity of D2 fold 30 (9.43%). Of Pts with abnormal D2 finding 24 had celiac disease, 6 had Giardiasis on histology. Out of 318 pts with gastritis and ulcerations 196 (61.65%) had Biopsy Urease test Positive. CONCLUSIONS: In this study H. Pylori infection is most commonly present. G.I. Infestation of parasite is second common cause wth Malignancy is third common cause of IDA Due to chronic GI Blood loss. As significant no. of patients with Normal endoscopic findings had abnormal Histology a standard routine protocol of biopsie should be recommended in IDA patients. Conflict of Interest: None declared.

P213V: DUODENAL ASCARIASIS Ramanathan Sabarinathan1, Krishnamoorthy Veeraraghavan2, Ratnakar Kini2, Thangavel Pugazhendhi2 Madras Medical College 1Institute of Medical Gastroenterology, and 2Medical Gastroenterology, Chennai, India

AIMS: Video demonstration of multiple Ascaris lumbricoides in duodenum. METHODS: A 27-year old gentleman who presented with the history of epigastric pain and vomiting for about two weeks was admitted for evaluation. Routine blood investigations revealed mild anaemia (9.8 g%), with normal renal and liver function tests. Subsequent ultrasonogram of abdomen was also normal. On further probation an upper gastrointestinal endoscopy was done, visualized multiple motile ascaris lumbricoides (round worms) in the bulb and second part of the duodenum.

RESULTS: A prompt decision was made and the worms were removed endoscopically using polypectomy snare and dormia basket. Further, he was treated with oral mebendazole 100 mg twice daily for 3 days and iron supplements. Later following worm extraction and anthelmintic therapy, the patient was found to be asymptomatic during the follow up visit. CONCLUSIONS: Being tropical countries are endemic to parasitic infestation, the role of endoscopy in diagnosis and treatment is noteworthy. Conflict of Interest: None declared.

METHODS: 368 patients (204 M, 164 F) (median age 44, range 20–74) with unexplained anemia, without GI symptoms


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P214: A STUDY OF CLINICAL AND ENDOSCOPIC PROFILE OF ACUTE UPPER GASTROINTESTINAL BLEEDING IN A TERTIARY CARE CENTRE IN EASTERN ODISHA Sambit Kumar Behera, Sivaram Prasad Singh, Chitta Ranjan Panda, Sunil Mishra, Debakanta Mishra, Suryakanta Parida, Kaibalya Ranjan Dash, Prasanta Parida, Girish Kumar Pati, Preetam Nath SCB Medical College, Cuttack, India

AIMS: To study the clinical and endoscopic profile of acute upper gastrointestinal bleed to know the etiology, clinical presentation, severity of bleeding and outcome. METHODS: This is a prospective, descriptive hospital based study conducted in Department of Gastroenterology, SCB Medical College &Hospital, Cuttack, Odisha, India from January 2015 to August 2016. It included 240 patients at random presenting with manifestations of upper gastrointestinal bleed. Their clinical and endoscopic profiles were studied. Rockall scoring system was used to assess their prognosis.

RESULTS: Males were predominant (72%). Age ranged from 15 to 80 years, mean being 47.34 + 16.73. At presentation 124 patients (51.6%) had both hematemesis and malena, 80 patients (33.33%) had only malena and 36 patients (15%) had only hematemesis. Shock was detected in 28.5%, severe anemia and high blood urea were found in 42.2% and 48.3% respectively. Upper Gastrointestinal Bleeding endoscopy revealed esophageal varices (26.6%), peptic ulcer disease (56.6%), erosive mucosal disease (8%), Mallory Weiss tear (3.3%) and malignancy (5%). Median hospital stay was 6.23 + 2.45 days. Comorbidities were present in 73.3%. 180 patients (75%) had Rockall score < 5 and 80 (25%) had >6. Twelve patients (5%) expired. Risk factors for death being massive rebleeeding, comorbidities and Rockall score >6. CONCLUSIONS: Acute Upper Gastrointestinal bleeding is a medical emergency. Mortality is associated with massive bleeding, comorbidities and Rockall score >6. Urgent, appropriate hospital management definitely helps to reduce morbidity and mortality. Conflict of Interest: None declared.

P215: ENDOSCOPIC MANAGEMENT OF CAUSTIC ESOPHAGEAL STRICTURE Neeraj Nagaich1, Radha Sharma2 1

Fortis Escort Jaipur, Gastroenterology, and 2RUHS CMS, Pathology, Jaipur, India

AIMS: To determine the outcome and safety of esophageal dilatation in caustic esophageal strictures in the study group. And subgroup analysis of refractory esophageal stricture.

METHODS: This descriptive study was conducted to evaluate the safety and efficacy of endoscopic dilatation in corrosive esophageal stricture. Patients were initially evaluated with barium swallow and meal. Savary Gilliard plastic dilators of increasing sizing were employed. Repeated sessions were performed fortnightly till a 15 mm (45 Fr) lumen size was achieved. Follow up session were arranged whenever dysphagia developed. In patients with refractory stricture Injection Triamcinolone or topical Mitomycin C application was done during dilatation session.

RESULTS: Out of 320 patients, 192 patients (60%) were more than 12 years of age. Mean age is 20.25 ranging from 5 years to 64 years. There were 185 males (58%) and 135 females (42%). Total dilatations were 4822. Successful dilatation up to a lumen size of 15 mm could be achieved in 211 patients (66%). In 48 patients (15%) with refractory stricture application of triamcinolone or Mitomycin c lead to success. In 108 patients (34%) satisfactory dilatation could not be achieved and were referred for surgery. 9 patients (2.8%) had perforation with an incidence rate of 0.30%. CONCLUSIONS: Caustic Stricture is more common in adolescent and adults in our population. Endoscopic dilatation of esophageal strictures is a relatively safe procedure with good results and low rate of complications Resection with esophagogastric anastomosis or colonic interposition is required in severe cases. Injection Triamcinolone and topical Mitomycin may act as rescue therapy in refractory stricture. Conflict of Interest: None declared.

P216: ENDOSCOPIC COLONIC ESD WITH PERFORATION WITHOUT LAPAROSCOPIC ASSISTANCE FOR COLONIC SUBMUCOSAL TUMORS ORIGINATED FROM THE MUSCULARIS PROPRIA, COLONIC EARLY TUMOR AND LST Shengxi Li1, Meidong Xu2 People’s Hospital of Liaoning Province, and 2Digestive Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China 1

AIMS: This foresight study was designed to evaluate the clinical safety and feasibility of clip closeed colonic ESD in perforation for colonic submucosal tumors (SMTs) originated from the muscularis propriacolonic, early tumor and LST. METHODS: Twenty-one patients with colonic SMTs originated from the muscularis propria and More than 2.0 cm of LST and colonic early tumor were treated by ESD between January 2012 and July 2016. Operation steps of these patients with ESD consists of four major procedures: (1) injecting normal saline into the submucosa and precutting the mucosal and submucosal layer around the lesion;


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 (2) a circumferential incision as deep as muscularis propria around the lesion which All supervened different degree of perforation; (3) completion of incision to the tumor with Hook, IT, or snare by colonoscopy (4) closure of the defect in Intestinal wall with metallic clips.

RESULTS: Of the 21 SMTs originated from muscularis propria that were adhesive to serosa and more than 2.5 cm of LST, 9 were located in sigmoid colon, 4 in the Descending colon, 5 in transversum colon, 3 in ascendens colon With ESD procedure, we successfully removed all of the lesions with perforation and the perforation were Successfully closed and no laparoscopic assistance or surveillance was needed. The Postoperative wound healing rate was 100% (21/21). CONCLUSIONS: Colonic ESD with perforation that was closed by metallic clips seems to be an safe, feasible and minimally invasive treatment for patients with colonic SMT, early cancer and adenoid tumor, EFR procedure will be performed in future in colon. Conflict of Interest: None declared.

P217: MANAGING GI BLEED IN CARDIAC PATIENTS, FACING THE STORM Neeraj Nagaich1,2, Radha Sharma3 1

Fortis Escort Jaipur, Gastroenterology, 2Metro MAS Hospital, Gastroenterology, and 3RUHS CMS, Pathology, Jaipur, India

AIMS: To describe the clinical and endoscopic characteristics of patients with UGIB in cardiac patients and characterize predictors of outcome. METHODS: Prospective and Retrospective study of 655 consecutive patients with UGIB in cardiac patients from 2013 to 2016. Demographic characteristics, Therapeutic management, and predictors of outcomes were determined.

RESULTS: 71.1% were male, mean age: 58.8 9.2 years, mean Commonest symptoms included melena (49.4%) or coffee ground emesis (35.8%). In-hospital medications included heparin (92.4%, ASA (78.5%), low molecular weight.9%), coumadin (48.1%), clopidogrel (31%), and NSAIDS (32%). Initial hemodynamic instability was noted in 33.1%. Associated laboratory results included hematocrit 28 6, platelets 243 133 109/L, INR 1.7 1.6, and PTT 53.3 35.6 s. Endoscopic evaluation (650 patients) yielded ulcers (73.5%) with high-risk lesions in 39.5%. Ulcers were located principally in the stomach (22.5%) or duodenum (45.9%). Many patients had more than one lesion, including esophagitis (30.7%) or erosions (22.8%). 37.8% received endoscopic therapy. Mean lengths of intensive care unit and overall stays were 9.4 18.4 and 30.4 46.9 days, respectively. Overall mortality was 5.1%. Only mechanical ventilation under 48 h predicted mortality (OR = 0.11; 95% CI = 0.04 0.34).


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CONCLUSIONS: Most common cause of UGIB in cardiac patients was from ulcers or esophagitis; many had multiple lesions. ICU and total hospital stays as well as mortality were significant. Mechanical ventilation for under 48 h was associated with improved survival. Early diagnosis and prompt treatment can improve prognosis. Conflict of Interest: None declared.

P218: GASTROINTESTINAL HEMORRHAGE FROM DIEULAFOY’S LESION: CLINICAL SPECTRUM AND EFFICACY OF ENDOSCOPIC THERAPY Harshal Shah, Hrushikesh Chaudhari, Nitin Jagtap, Sundeep Lakhtakia, Mohan Ramchandani, Manu Tandon, D. Nageshwar Reddy Asian Institute of Gastroenterology, Medical Gastroenterology, Hyderabad, India

AIMS: We evaluated prospectively clinical outcome of endoscopic therapy in patients with gastrointestinal hemorrhage in patients with Dieulafoy’s lesion. METHODS: 40 consecutive patients with Dieulafoy’s lesions were analysed at Asian Institute Of Gastroenterology, Hyderabad, India between January 2012 and July 2016. Demographic characteristics, endoscopic features, and clinical outcome were reviewed.

RESULTS: A total of 40 patients (men - 24; 60%) with mean age of 54.7 years ( 19.42) were presented with Dieulafoy’s lesion. Most common presentation was combined hemetemesis and malena (n = 22, 55%) followed by hematemesis (n = 12) and hematochezia (n = 6). Most common location was duodenum (n = 15, 37.5%) followed by gastric (n = 12), jejunum (n = 11) and colon (n = 2). Upper GI Endoscopy was successful in detecting 27 of the lesions (67.50%), 22 in first attempt while 3 patients required re-look endoscopy and 2 were detected on EUS. Colonoscopy diagnosed the lesion in 2 patients while 11 lesions were detected with capsule endoscopy followed by Enteroscopy. Majority of patients underwent endoscopic hemoclips application (n = 30 - 75% out of which UGI endoscopy-17, per-oral enteroscopy-11 and colonoscopy-2), and Endoscopic Band Ligation (EBL) was performed in remaining (n = 10, 25%). Out of 17 patients who underwent Endoscopic hemoclips application, 12 lesions were detected in duodenum and 5 in stomach; whereas EBL was performed in 7 gastric lesions and 3 duodenal lesions. Initial haemostasis was achieved in all 40 cases (100%); however recurrent bleeding occurred in 4 patients - out of whom 2 underwent endoscopic hemoclips application (1gastric, 1-duodenal), one underwent surgical resection of jejunal lesion and a single duodenal lesion required angiography coil embolization. CONCLUSIONS: Dieulafoy’s lesions are major cause massive gastrointestinal bleeding. Endoscopic therapy should be initial therapeutic modality for bleeding Dieulafoy’s lesion. In case of


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endoscopic therapy failure, endoscopic re-intervention, angiographic coil embolization or surgery can be performed. Conflict of Interest: None declared.


P220: UPPER GASTROINTESTINAL DISEASES IN PATIENTS FOR ENDOSCOPY IN SOUTH WESTERN UGANDA Siraji Obayo

P219: STUDY OF DEMOGRAPHIC, CLINICAL, AETIOLOGICAL PROFILE, H. PYLORI ASSOCIATION AND OUTCOME OF THE PATIENT WITH NON VARICEAL UPPER GI BLEED Manish Kumar Bhaskar IMS BHU, Gastroenterology, Varanasi, India

AIMS: Attempt to prospectively analyze patients admitted to Department of Gastroenterology SSH Varanasi with Nvugi Bled.

METHODS: Study was carried out over a period of 18 months. Total no. of patient screened were 387, out of which 260 patients were endoscopically proven to have variceal bleeding and were excluded. The remaining 127 cases were initially included in the study. In another 13 cases, an endoscopic dignosis could not be reached and hence they were excluded from the study. 114 patients were subjected to detailed clinical history and examination.

RESULTS: Eighty two (71.9%) males, 32 (28.1%) females. The m:f ratio 2.56:1. The mean age was 48.97 years and the range was 18–82 years. Eighteen pt (15.7%) had a past history of ugi bleeed. Forty six pt. (40.35%) gave history of NSAID ingestion. The most common presentation was malena (47.83%) followed by hematemesis (38.04%). Both hematemesis and malena were present in 20 pt.25 pt. (21.9%) presented with shock. EMD was the commonest cause (34.8%) followed by du (19.6%) and esophagitis (13%). Malignancy constituted only 5.4% Pt. were assessed for association of H. pylori and peptic ulcer disease. It was detected in 89% of DU and 75% of GU by using RUT. Histology was positive in 77.8% of DU and 87.5% of GU. Both RUT and histology were positive in 72.2% of DU and 75% of GU. Seventy five pt. (81.5%) who presented with nvugi bleed setteled without any adverse outcome. Nine (7.89%) rebled out of which 4 had du, 3 had GU and 2 had MWT. Of the 9 pt. (7.9%) who died 3 had DU, 2 had GU, 2 had carcinoma stomach, 1 had carcinoma esophagus and 1 had EMD. CONCLUSIONS: Parameters significantly increase the risk of adverse outcome were age >60, epigastric years, hematemesis pain 2 as inadequate preparation. At the time of endoscopic examination, the patients filled up a questionnaire about detailed medication history, dietary status before 48 h of exams, total uptake of preparation uptake and complication associated with preparation and so on.

RESULTS: Mean age of the patients was 58.7 12.9 years and 60.3% were male. Regarding bowel preparation schedule, 41.3% of patients use single dose regimen and 58.7% of patients conduct split dose regimen. Of the 208 patients, overall bowel preparation was inadequate in 79 exams (38.0%). Bowel preparation scale of ascending colon was significantly higher than the other colon segments. In patients with inadequate bowel preparation, proportion of age older than 60 years, diabetes, history of abdominal surgery, especially history of gastrectomy and appendectomy, single regimen was significantly higher and total amount of preparation solution was significantly less than those of adequate preparation. By multivariate analysis, age above 60 years, history of gastrectomy and single regimen was independent predictors of inadequate bowel preparation. On the other hand, total amount of solution uptake more than 3 L showed a preventive effect (OR 0.571, P = 0.03). CONCLUSIONS: Risk factors associated with inadequate bowel preparation were age older than 60 years, history of gastrectomy and single dose regimen. Split dose regiment with enough amount of preparation solution uptake is needed to be thoroughly instructed, especially in old patients with history of gastrectomy. Conflict of Interest: None declared.




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P226: A COMPARATIVE STUDY FOR POLYETHYLENE GLYCOL AND ASCORBIC ACID WITH ADJUNCTIVE METOCLOPRAMIDE IN BOWEL PREPARATION OF COLONOSCOPY

P227: EVALUATION OF A 1.2-LITER POLYETHYLENE GLYCOL PLUS ASCORBIC ACID SOLUTION AS AN OUTPATIENT BOWEL PREPARATION FOR COLONOSCOPY IN JAPANESE PATIENTS

Jung Min Lee, Jae Min Lee, In Kyung Yoo, Seung Han Kim, Hyuk Soon Choi, Eun Sun Kim, Bora Keum, Yoon Tae Jeen, Hoon Jai Chun, Hong Sik Lee, Chang Duck Kim

Hiroyuki Tamaki, Masahiro Morita, Teruyo Noda, Masako Izuta, Atsushi Kubo, Chikara Ogawa, Toshihiro Matsunaka, Mitsushige Shibatoge

Korea University Anam Hospital, Divison of Gastroenterology, Seoul, Korea

Takamatsu Red Cross Hospital, Gastroenterology, Takamatsu, Japan

AIMS: Although various adjuncts have been proposed to improve the quality of bowel cleansing for colonoscopy and patient’s tolerability, the efficacy of prokinetics is still remains unclear. In this study, we evaluated the effect of metoclopramide as adjunctive agent for colonoscopy bowel preparation using polyethylene glycol and ascorbic acid.

AIMS: The present study aimed to compare a 1.2-liter polyethylene glycol plus ascorbic acid solution (PEG-ASC) using a simplified original protocol and a standard-volume polyethylene glycol-based electrolyte solution (PEG-ELS) in terms of the cleansing efficacy and tolerance among individuals scheduled for outpatient colonoscopy.

METHODS: We conducted a prospective, randomized, com-

METHODS: A randomized, single-blinded, open-label, single

parative study for adjunctive metoclopramide in bowel cleansing. A total of 192 patients were enrolled and randomly assigned to the group with metoclopramide (n = 96) or not (n = 96). An oral dose of 10 mg metoclopramide was administered about 30 minutes before split-dose of 2 litter polyethylene glycol and ascorbic acid (PEG+Asc). The experimental parameters included bowel cleansing quality (Boston bowel preparation scale and Aronchick scale), time to first defecation, time to bowel cleansing completion, and adenoma detection rate. The questionnaires reporting the acceptability and tolerability were also collected from patients.

center, non-inferiority study was conducted. Three hundred twelve Japanese adult patients who underwent colonoscopy were enrolled. Patients were randomly allocated to bowel lavage with either 1.2-liters of PEG-ASC solution with at least 0.6 liters of an additional clear fluid (group M) or 2.0 liters of PEG-ELS (group N).

RESULTS: Administration of metoclopramide before taking PEG+Asc showed a significant improvement of bowel cleansing quality. Total Boston bowel preparation scale was higher in the group of metoclopramide than control (7.6 1.6 vs 6.6 1.4, P = 0.001). The patients with adequate cleansing were 96% (95% CI 91–99) in metoclopramide group and 93% (95% CI 88–98) in control group. However, the average time for first defecation, completion of bowel preparation, and adenoma detection rate showed no significant difference between the patients with or without adjunctive metoclopramide. Abdominal fullness and uncomfortable abdominal symptoms were improved with adjunctive oral metoclopramide.

RESULTS: Two hundred ninety-one patients (group M, 148; group N, 143) completed the study. There was no significant difference in successful cleansing, defined as a BBPS score ≥2 in each segment, between the two groups (group M, 91.9%; group N, 90.2%; 95% CI –3.04% to 8.97%). Thus, PEG-ASC demonstrated non-inferiority to PEG-ELS with a non-inferiority margin of 10%. The required time to bowel preparation was significantly shorter (164.95 68.95 vs 202.16 68.69 min, P < 0.001) and the total volume of fluid intake was significantly lower (2.23 0.55 vs 2.47 0.56 litres, P < 0.001) in group M than in group N. Although there was no difference in overall patient tolerance between groups M and N (no discomfort: 81.8% vs 76.2%, respectively, P = 0.30), overall acceptability evaluated by using a patient questionnaire, which was assessed by the visual analogue scale was significantly better in group M than in group N (7.70 2.57 vs 5.80 3.24 cm, P < 0.001). No severe adverse event was observed in each group.

CONCLUSIONS: Adjunctive metoclopramide improves the

CONCLUSIONS: A 1.2-liter PEG-ASC solution was shown to be

quality of colonoscopy bowel preparation with split dose PEG+Asc. It is effective to decrease the uncomfortable symptoms such as abdominal fullness. Conflict of Interest: None declared.

non-inferior to a 2.0-liter PEG-ELS in terms of the cleansing efficacy, and it had better acceptability in Japanese patients. Conflict of Interest: None declared.


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P228: THE SAFETY OF LOW-VOLUME POLYETHYLENE GLYCOL CONTAINING ASCORBIC ACID FOR COLONOSCOPY IN PATIENTS WITH CHRONIC KIDNEY DISEASE Jae Min Lee, Byeong Kwang Choi, Sang Yup Lee, In Kyung Yoo, Seung Han Kim, Hyuk Soon Choi, Eun Sun Kim, Bora Keum, Yoon Tae Jeen, Hong Sik Lee, Hoon Jai Chun, Chang Duck Kim Korea University College of Medicine, Department of Internal Medicine, Seoul, Korea

AIMS: To investigate the safety and effectiveness of lowvolume polyethylene glycol (PEG) containing ascorbic acid in patient with chronic kidney disease. METHODS: A retrospective analysis was performed on 163 patients (n = 62, in PEG with ascorbic acid; n = 101, in PEG) with chronic kidney disease. The laboratory changes before and after bowel cleansing were compared between the groups. Quality of bowel preparation and patient questionnaire were also analyzed after colonoscopy.

RESULTS: In both groups of PEG containing ascorbic acid and PEG, there was no significant difference before and after bowel preparation. In both group, eGFR was not influenced by administration of bowel cleansing agent. Patient’s reports for tolerance and acceptability were shown better results in 2-L PEG plus ascorbic acid group than 4-L PEG group. No serious adverse event or significant changes were not observed following its administration. CONCLUSIONS: Our results showed the safety of the bowel cleansing with 2-L PEG plus ascorbic acid in patient with chronic kidney disease. Low-volume PEG containing ascorbic acid is a safe choice for colonoscopy under impaired renal function. Conflict of Interest: None declared.

P229: COMPARING OF EFFICACY OF BOWEL CLEANSING BETWEEN 2L ASCORBIC ACID MIXED PEG AND COMBINATION OF 1L ASCORBIC ACID MIXED PEG WITH BISACODYL PRIOR TO COLONOSCOPY Byeong Kwang Choi, Hyuk Soon Choi, Hoon Jai Chun, Yoon Tae Jeen, Bora Keum, Chang Duck Kim, Eun Sun Kim, Seung Han Kim, Hong Sik Lee, Jae Min Lee, Jung Min Lee, Sang Yup Lee, In Kyung Yoo Korea University Anam Hospital, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul, Korea

AIMS: Recently a low-volume polyethylene glycol containing ascorbic acid (PEG-Asc) formulation has proven as safe and effective as traditional 4-L PEG solutions for colonoscopy preparation. However, currently available aqueous purgative

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 formulations are poorly tolerated. The aim of this study was to compare a split-dose 2-L PEG-Asc and a 1-L PEG-Asc with bisacodyl (10 mg) formulation for quality of bowel cleansing while preparing for colonoscopy and patient compliance.

METHODS: A single center, randomized, observer-blinded study was performed between May 2015 and September 2015. Two hundred outpatients were prospectively enrolled. Patients referred for colonoscopy were divided into two groups: the split-dose 2-L PEG-Asc and 1-L PEG-Asc with bisacodyl 10 mg groups. The Boston Bowel Preparation Scale (BBPS) and Aronchick Preparation Scale (APS) were used to evaluate bowel cleansing with the two preparations. The tolerability and satisfaction of patients was determined based on a questionnaire-based survey.

RESULTS: One hundred patients received either 2-L PEG-Asc or 1-L PEG-Asc with bisacodyl. Regarding colon cleansing outcome (BPPS and APS), the 1-L PEG-Asc with bisacodyl group showed similar, but non-inferior results compared to the 2-L PEG-Asc group on both BBPS (6.92 1.63 vs 6.57 1.37, P = 0.103) and APS (96% vs 95%, P = 1.000) scales. Tolerability was similar for both 1-L PEG-Asc with bisacodyl and 2-L PEG-Asc. CONCLUSIONS: Our study shows the 1-L PEG-Asc plus bisacodyl preparation has comparable tolerability and results in adequate colon cleansing. Bowel preparation with bisacodyl and 1-L PEG-Asc is a suitable alternative to low volume bowel. Conflict of Interest: None declared.

P230: A DOUBLE-BLIND RANDOMIZED CONTROLLED TRIAL ON IMPLICATION OF PINAVERIUM IN COLONOSCOPY PROCEDURE Xiaolin Wang1,2, Hongyu Ren1, Jun Liu3 1 Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Department of Gastroenterology, 2Liyuan Hospital, Tongji Medical College, Huazhong University of Science and Technology, Department of Gastroenterology, and 3Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China

AIMS: To observe the effect of pinaverium on colonoscopy completing rate, scope-forward time, patients’ pain and polyp detection rate, including single-application, drug combination and single-application in different time period before colonoscopy. METHODS: One thousand and five hundred patients subjected to colonoscopy were double-blind randomly divided into single-application group and drug combination group. Pinaverium were administrated to patients in the single-application group before two days and one day of inspection and before inspection, while pinaverium plus adiphenine to those in the drug combination group before one day of inspection and adiphenine to those in the control group before inspection. The


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 colonoscopy completing rate, scope-forward time, patients’ pain and polyp detection rate were recorded by endoscopy doctor and assistance.

RESULTS: In the single-application group, the percentage of colonoscopy completing rate was higher and scope-forward time and patients’ pain was inferior when administrated before two days and one day of inspection than before inspection (P < 0.05). But the polyp detection rate respectively were 24%、26%、22.37%, and there was no significant difference (P > 0.05). There was no significant difference between the two groups adminiatrated before two days and one day of inspection (P > 0.05). In the drug combination group, the percentage of colonoscopy completing rate and polyp detection rate was higher, and scope-forward time and patients’ pain was inferior than using adiphenine singly and using pinaverium singly before one day of inspection (P < 0.05). CONCLUSIONS: It is effective that pinaverium were administrated before one day of inspection. The drug combination group is superior to the single-application group and the control group. As a result, it contributes to completing the colonoscopy, and shortening scope-forward time when administrated pinaverium before one day of inspection. But the effect of pinaverium plus adiphenine is even better, and improving polyp detection rate, which deserves clinic implication. Conflict of Interest: None declared.

P231: DIABETES AND CONSTIPATION ARE ASSOCIATED WITH INADEQUATE EXAMS IN SMALL VOLUME SPLIT DOSE PREPARATIONS (SDP) BUT NOT IN LARGE VOLUME SDP Hassan Siddiki, Sreya Ravi, Rahul Pannala, Francisco Ramirez, Douglas Faigel, Crowell Michael, Suryakanth Gurudu Mayo Clinic Arizona, Gastroenterology and Hepatology, Scottsdale, USA

AIMS: Adequate bowel preparation (BP) is associated with decreased rate of interval cancers. SDP is now standard of care but there is heterogeneity in literature regarding the optimal volume prescribed for split-dosing. We have previously reported that BP score of small-volume preparations is inferior to large volume. We wanted to identify factors that lead to inadequate-exams. METHODS: All patients undergoing outpatient screening/ surveillance colonoscopy using SDP were included between July 2014-Dec2014. Boston-Bowel Preparation Score (BBPS) was used to rate cleanse and a score ≤5 was considered “inadequate”. The small-volume group took 2 L polyethylene glycol (PEG) and large-volume took 4 L PEG. In univariate analysis we included age, gender, BMI, diabetes, constipation, diverticulosis and narcotic-use and previous surgeries. All multivariateanalysis (MVA) was controlled for age, gender and BMI. Primary outcome was rate of inadequate-exams.


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RESULTS: 1573 patients were included with mean (SD) age 61 (10), BMI 28 (5.6), 52% male. Large-volume-prep was used in 42% and small-volume in 58%. Mean BBPS was 6.77 (1.4). The rate of inadequate-exam was 15.6%. In MVA on all-comers, diabetes (OR1.77, 95%CI 1.23, 2.53; P = 0.002), narcotic use (OR1.87, 95% CI 1.17, 2.91; P = 0.01), constipation (OR1.54, 95%CI 1.00, 2.32; P = 0.048) were significantly associated with inadequate-exam. Prep volume was not significantly associated with outcome (P = 0.175). In MVA on small-volume group, diabetes (OR2.17, 95%CI 1.34, 3.45; P = 0.002) and constipation (OR1.75, 95%CI 1.05, 2.86; P = 0.034) were significantly associated with inadequateexam. In MVA of large-volume group, only age (OR1.03, 95%CI 1.00, 1.05; P = 0.024) was significantly associated with inadequateexam. No significant association was observed for diabetes (P = 0.251) or constipation (P = 0.607). Narcotic use was marginal (OR2.02, 95%CI 0.94, 4.05; P = 0.071). CONCLUSIONS: For prescribing optimal volume in the era of SDP, one size does not fit all. If the patient has diabetes and/or constipation, low-volume SDP may result in inadequate-exam. The rate of inadequate-exams for such patients is less with large-volume SDP. Conflict of Interest: None declared.

P232: SHAVASAN AN ANCIENT YOGIC METHOD (DEAD BODY POSITION) TO REDUCE STRESS DURING UPPER GASTROINTESTINAL ENDOSCOPY Mool Kotwal1, Susrutha Kotwal2 1 Medical Adviser to the Chief Minister of Sikkim, Home & Health, Gangtok, India and 2Johns Hopkins University, Department of Medicine, Baltimore, USA

AIMS: Study was to examine the effects of SHAVASAN (A Yogic Posture for relaxation). YOGA has been universally accepted as a stress buster by the United Nations. gastrointestinal endoscopy service requires a suitable ambient environment. Many patients fear GI endoscopy. Natural anxiety may be aggravated by horror stories from friends or inappropriate remarks by endoscopy staff. Yogic techniques in general and Shavasan in particular are known to improve psychosomatic health and enhance one’s ability to combat stressful situations. METHODS: This study was conducted on 63 consecutive patients undergoing endoscopy for various reasons. Patients were randomly assigned to two groups regardless of sex, age and underlying disease. Thirty two patients relaxed in Shavasan before the procedure. Control group had 31 patients. Blood pressure, heart rate, and respiratory rate were recorded at the beginning and end of procedure. Perception of procedure using a 5 point attitude scale was assessed.

RESULTS: Relaxation in Shavasan is effective in reducing stress during gastroscopic examination and other medical situation. Statistically significant difference in systolic blood


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pressure, heart and respiratory rate was recorded in experimental (Shavasanic yogic group). Control group did not show any change in the parameters. Acceptance of procedure using a 5 point scale was more in the Experimental group.

vomiting during the bowel preparation were the factors related to non acceptance of colonoscopy. Conflict of Interest: None declared.

CONCLUSIONS: Preliminary study to see the effects of Shavasan yoga in anxiety and stress in Upper GI Endoscopy subjects. Useful in disorders that generate anxiety and stress. Shavasan and its variations like deep breathing require further studies for evaluation of therapeutic effects in a wide range of functional disorders. Shavasan Yoga is a highly interesting field for further research. Shavasan YOGA a life style modifier potentially can be used in many functional and modern day stress related disorders. Conflict of Interest: None declared.

P233: ACCEPTANCE OF COLONOSCOPY IN MOROCCAN TERTIARY CENTER 1

2

Mohammed Tahiri Joutei Hassani , Wafaa Hliwa , Haddad Fouad2, Ahmed Bellabah2, Wafaa Badre2 University of Casablanca 1Gastroenterology, and 2 Casablanca, Morocco

AIMS: To assess the acceptance of colonoscopy in Moroccan patients, and to determinate factors related to colonoscopy acceptance. METHODS: We conducted a prospective, non-randomized study in IBN Rochd University Hospital center. Analysis of the acceptance of colonoscopy at three stages (pre, post, and during) through a checklist was done : patient´s questionnaire and a medical assessment form were used. A multiple stepwise logistic regression model was used to determinate factors related to colonoscopy acceptance. Two hundred and three patients who underwent colonoscopy with or without sedation were prospectively recruited from January 2014 to June 2015

RESULTS: In this study, the mean age of patients was 47.2 17.9 years. 90.6% of patients had positive acceptance of colonoscopy. Female gender, abdominal pain, both during the bowel preparation and after the procedure, anxiety before the procedure, vomiting during the bowel preparation and nonsedated colonoscopy were related to patients non acceptance of colonoscopy.

P234: TOTAL COLONOSCOPY WITH LOW DOSE PREPARATION AND WATER-EXCHANGE TECHNIC Hong Ouyang 2nd Affiliated Hospital of Hangzhou Medical University / The People’s Hospital of Lin’an City, Lin’an, China

AIMS: To observe the feasibility and efficacy of combining water-assist colonoscopy technic with low dose colon preparation and conventional device. METHODS: 20 patients without bowl habit abnormality is recruited. Each is given 30 mL 66.7% lactose oral solution the night before examination. One experienced colonoscopist examined all subjects with conventional endoscopy equipped with water pump and forward water jet. Sedation is not used for all patients. There are 19 patients who is willing to take unsedated total colonoscopy with conventional 2L PEG solution preparation in the same period of time. They are invited to scope by the same doctor. Inserting time, bowl movement, lumen cleanness and pain index is documented and compared.

RESULTS: All patient achieved cecum intubation and results listed in table 1. [Table 1] CONCLUSIONS: Water-assist total colonoscopy could be achieved with low dose preparation. Bowl movement and pain is much less than conventional preparation and technic, hens much comfortable for the patient. Inserting time is nearly doubled with water-assisted technic. This might be the muddy water makes it harder to identify cecum before exchange water into air. And suction under water with conventional device is prone to cause small mucosa rupture. Conflict of Interest: None declared.

CONCLUSIONS: Colonoscopy is highly acceptable procedure in Morocco. Female gender, abdominal pain, anxiety and

Group

Intubation time

A B P-value

11.45 3.46 5.58 2.43 0.0000

Pain index 2.05 1.23 3.58 1.42 0.0009

Bowl movement 3.80 0.77 7.16 1.34 0.0000

Lumen cleanness score Ascending 2.45 0.69 2.05 0.23 0.0222

Transcending 2.95 0.22 2.89 0.32 0.5300

Descending 2.90 0.30 2.26 0.45 0.0000


Total 8.30 1.03 7.21 0.61 0.0000


CLINICAL ENDOSCOPIC PRACTICE: ENDOSCOPY: QUALITY MEASURES AND QUALITY IMPROVEMENT P235: FACTORS THAT LED TO INCREASED NUMBER OF TOTAL COLONOSCOPIES Mira Turbekova Science Research Institute of Cardiology and Inner Diseases, Almaty, Kazakhstan

AIMS: The purpose of the research is to identify the main factors that increase the colonoscopy completion rate. METHODS: Questionnaires are filled up by 108 endoscopists (67 males, 41 females), who were trained at the Kazakh Medical University of Livelong Learning and Research Institute of Cardiology and Internal Diseases in 2015. Logistic regression model applied. The dependent variable is the cecal intubation rate (“0” - less than 90%, “1” - above 90%). Investigated factors: experience in conducting colonoscopy, training in colonoscopy, number of colonoscopies performed during last year, participation in CRC screening. Independent variables are assessed by Wald chi-square.

RESULTS: Only half of the respondents achieved the proposed standard in their work (57 endoscopists, 52.8%). Colonoscopy completion rate depends on the number of procedures per year (P < 0.001), experience of endoscopist (P = 0.002) and participation of a doctor in screening colonoscopies (P = 0.041), but does not depend on the duration of last training (P = 0.460). Adjusted odds ratios (OR) showed that the number of colonoscopies per year significantly affects the improvement of the cecal intubation rate. Performing more than 200 procedures per year increases the chance of achieving standard quality indicator in 5.05 (95%CI: 1.69–15.06) fold compared with the group physicians who perform less than 100 colonoscopies per year (P = 0.004). Among endoscopists with colonoscopy experience more than 5 years the chance to achieve quality standard is 7.74 (95% CI: 1.44–41.67) times higher in contrast to the doctors working less then 1 year (P = 0.017). CONCLUSIONS: Conducting more than 200 colonoscopies per year significantly improves the performance of complete colonoscopies (P = 0.004). Conflict of Interest: None declared.

P236: THE STUDY OF THE RESULTS OF DUODENOSCOPE CHANNELS BY DIFFERENT DISINFECTION METHODS Su Ma, Huijun Xi Changhai Hospital, Shanghai, China


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AIMS: To study the effect of the different kinds of methods disinfecting duodenoscope channels (the biopsy channel and the elevator channel). METHODS: 30 samples were measured randomly from 20th Oct, 2015 to 17th Nov, 2015 in a grade A tertiary Hospital, Shanghai. Group A (N = 10), using the automatic cleaning sterilizer with OPA. Group B (N = 10), using manual cleaning and disinfection with OPA. Group C (N = 10), using the automatic cleaning sterilizer with peracetic acid. Collected and compared the data of bacterial colonies number of different groups, analyzed by SPSS19.0.

RESULTS: The disinfection eligible rate of duodenoscope is 16.67%. There is no difference between the clump count of biopsy channel and elevator channel among three groups (P > 0.05). The elevator channels’ bacterial colonies number of group A are higher than that of group C (P < 0.05). The elevator channels’ bacterial colonies number of group A are higher than that of group B (P < 0.05). CONCLUSIONS: The disinfection eligible rate of duodenoscope is low. There is no distinction between the clump count of biopsy channel and elevator channel with different cleaning and disinfection methods. For the elevator channel, using peracetic acid is better than OPA (in the same “automatic cleaning sterilizer” condition), and manual cleaning and disinfection is better than automatic cleaning sterilizer under the same ”using OPA” condition. Conflict of Interest: None declared.

P237: EIR: CHANGING THE SCENE OF AUTOMATIC DETECTION SOFTWARE FOR GASTROINTESTINAL ENDOSCOPY Sigrun Losada Eskeland1, Lars Aabakken2, Michael Alexander Riegler3, Peter Thelin Schmidt4,5, Dag Johansen6, Pal Halvorsen3,7, Thomas de Lange8 1

Vestre Viken Hospital Trust, Department of Medical Research, Bærum Hospital, Drammen, Norway, 2Oslo University Hospital Rikshospitalet, Department of Transplantation Medicine, Oslo, Norway, 3Simula Research Laboratory, Oslo, Norway, 4Karolinska Institutet, Department of Medicine, Solna, Sweden, 5Karolinska University Hospital, Center for Digestive Diseases, Stockholm, Sweden, 6The Arctic University of Norway, Tromsø, Norway and 7University of Oslo, Oslo, Norway, 8 Cancer Registry of Norway, Oslo, Norway

AIMS: The aim is to develop an automatic disease detection system for gastrointestinal (GI) endoscopy. Our initial focus is polyp detection due to its high relevance in colorectal cancer prevention. METHODS: The EIR automatic disease detection software has been developed using a combination of image processing, global image features and search-based classification. The


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modular system allows stepwise training for different gastrointestinal lesions. To test the polyp detection accuracy of EIR, we combined two datasets. From the Karolinska University Hospital (Sweden), we used white light images of 44 adenomas, 4 inflammatory polyps and 146 different non-polyp GI diseases. From the ASU Mayo Clinic (US), we used 1760 non-polyp images, containing both a wide range of GI diseases and normal findings. EIR was trained with images from the Vestre Viken Hospital Trust (Norway) where we have 82 polyp images and 425 non-polyp images. The detection accuracy was tested blinded for the annotations.

RESULTS: The sensitivity of the detection module is 1.000, the specificity is 0.8929. PPV is 0.1905, and NPV is 1.000. False positives occurred in images displaying lesions with appearance similar to polyps. This can probably be avoided by training the system to detect these as separate classes or by better training data.

Classified as polyp Not classified as polyp Total

Polyp

No polyp

Total

48 0 48

204 1702 1906

252 1702 1954

[Result from EIR polyp detection]

CONCLUSIONS: EIR demonstrates high sensitivity and specificity for polyp detection using diverse datasets from different sources (hospitals). This proves that the classification performance is robust and not over-fitted. Further testing is necessary, but the results indicate great potentials for developing a fully automated GI disease detection system. Conflict of Interest: None declared.

practitioners while fluoroscopy was working. Radiation doses were monitored quarterly by thermoluminescent dosimeters (TLD) worn at inside of window shield (at the level of neck; TLD1), neck (outside of thyroid shield; TLD2) of endoscopist, and chest (under the apron; TLD3 and TLD4) of endoscopist and a main assistant.

RESULTS: 185 consecutive therapeutic ERCP procedures were performed at our hospital between July 2014 and March 2015. Mean age of patient was 67 years. Mean fluoroscopy time was 168 seconds. Mean number of digital radiographs per procedure were 3.8. The radiation doses of inside (TLD1) and outside (TLD2) of lead window at the neck level were 9.35 vs 0.33 mSv, 8.62 vs 0.25 mSv, and 8.82 vs 0.31 mSv in every three quarter, respectively. Self-designed shield reduced the radiation exposure significantly (P < 0.001). There was no significant radiation doses’ difference between in neck level of endoscopist (TLD2) and in chest level of endoscopist (TLD3) and assistant (TLD4). CONCLUSIONS: Radiation dose to endoscopist from ERCP far exceeded 20 mSv in less than 9 months. It suggested endoscopist may be exposed to significant values of radiation from ERCP without shield. Our self-designed protective lead shield can significantly reduce personnel’s radiation exposure. Conflict of Interest: None declared.

P239: A STUDY OF VOICE OF CUSTOMERS ABOUT GASTROINTESTINAL ENDOSCOPY DURING HEALTH CHECKUP Jong In Yang Seoul National University Hospital Gangnam Center, Department of Internal Medicine, Seoul, Korea

P238: RADIATION EXPOSURE CAN BE SIGNIFICANTLY REDUCED DURING ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY WITH SELF-DESIGNED PROTECTIVE SHIELD

AIMS: Gastrointestinal endoscopy is an essential examination during health checkup for detecting cancer or precancerous lesion although it may be uncomfortable. The aim of our study was to find potential points for improving satisfaction to the endoscopic examinations by exploring the actual VOC (Voice of Customers) during health checkup.

Byoung Kwan Son, Yoon Suck Bak, Hee Yun Ryu

METHODS: VOC records about gastrointestinal endoscopy at

Eulji University, Nowon Eulji Hospital, Seoul, Korea

AIMS: Endoscopic Retrograde Cholangiopancreatography (ERCP) using fluoroscopy should be practiced with adequate radiation protection. Reducing radiation exposure of medical personnel is an important issue. Individual protective devices can’t protect entire body from radiation. This study was planned to investigate personnel’s radiation doses obtained from ERCP with overcouch X-ray tube and the efficacy of the self-designed lead window shield. METHODS: We produced a 2 mmPb plate shield (width: 120 cm, height: 190 cm) with 0.5 mmPb window (width: 115 cm, height: 60 cm) on its upper part. This wheeled protective shield was placed between the patient and

Seoul National University Hospital healthcare System Gangnam Center from 2010 to 2015 were analyzed retrospectively. Each VOC was sorted according to the sort of gastroscopy or colonoscopy and the proposed timing of before, during, or after endoscopy.

RESULTS: A total of 138 VOCs were occurred. 77 were about gastroscopy and 61 were about colonoscopy. VOC occurrence during endoscopy was higher in gastroscopic VOC subjects but that before endoscopy was higher in colonoscopic VOC subjects. Sore throat after gastroscopy was the most common VOC about gastroscopy. Difficulty in drinking colonic lavage preparation due to bad odor or taste was the most common VOC about colonoscopy.


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 CONCLUSIONS: Timing of VOC occurrence may differ between gastroscopy and colonoscopy. Gentle insertion, adequate sedation and enhancing the odor and taste of colon lavage preparation may enhance satisfaction to endoscopic examination during health checkup. Conflict of Interest: None declared.

P241: BENCHMARKING ENDOSCOPY SERVICES IN IRAQ - RESULTS OF A NATIONAL SURVEY Laith Al Rubaiy1, Ali Al-Rubaye2, Moayed Aziz3, Neil Hawkes3, Bethan Hawkes3 1

Swansea University, College of Medicine, Swansea, UK, Basra General Hospital, Basra, Iraq and 3Prince Charles Hospital, Merthyr Tydfil, UK

2

AIMS: We sought to benchmark practice against UK quality standards by surveying the main training centres and service providers of endoscopy in Iraq.

METHODS: A Survey Monkey questionnaire with 40 questions relating to local endoscopic practice and based on defined areas of the GRS was sent to departmental leads in all regional centres in Iraq performing GI endoscopy by the President of the Iraqi Medical Society International. 24/35 responses (69%) were received (all 12 major institutions responded).

RESULTS: All Units perform diagnostic upper and lower GI endoscopy. Whilst 90% perform some ERCP, only half perform >250 per year. Figures for EUS were similar (85% some EUS, 55% >250 cases per year). Enteroscopy is only performed in small numbers. No agreed performance standards exist on a national level. Access to modern endoscopes, accessories and diathermy was acceptable. Survey data aligned to the patient experience, quality of procedure, workforce and training highlighted resource and training gaps: only 70% of respondents use a structured referral form with stratification of urgent cases, 54% are able to vet appropriateness of referral and 20% can effectively audit referral practice. Written information about procedures is limited and the practice of informed consent falls short of UK standards. Numbers of recovery beds and staffing levels varied widely. Patient monitoring equipment was not universally available. 47% have an ERS, 47% paper-based records and 16% no reporting system. Morbidity and mortality, sedation practice and patient experience were recorded in less than half of responding institutions. Centres with a large numbers of trainees tend to have experienced trainers but assessment tools and training goals varied across institutions.


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P242: ADHERENCE TO GUIDELINES FOR ENDOSCOPIC MANAGEMENT OF ACUTE UPPER NON-VARICEAL GASTROINTESTINAL BLEEDING Mohamed Hasmoni1, Azlida Che Aun2, Hoi Poh Tee2, Khairul Azhar Jaafar1 1 International Islamic University Malaysia, Department of Internal Medicine, and 2Hospital Tengku Ampuan Afzan, Department of Medicine, Kuantan, Malaysia

AIMS: The combination of various endoscopic treatment modalities is superior to single endoscopic treatment. This study aims to assess the adherence to ‘best practice’ standards for patients with non-variceal upper gastrointestinal bleeding with high risk stigmata on endoscopic findings. METHODS: Between January and July 2016, consecutive charts of patients hospitalized for acute upper gastrointestinal bleeding in Hospital Tengku Ampuan Afzan, Kuantan were reviewed. Data regarding initial presentation, endoscopic findings and treatment, as well as endoscopists were collected. Patients with high risk stigmata on endoscopic findings were included; active bleeding, spurting (Forrest Ia), active bleeding, oozing (Forrest Ib), non-bleeding visible vessel (Forrest IIa) and adherent clot (Forrest IIb). Since the combination treatment was superior to a single treatment modality, the emphasis was on the number of endoscopic treatment modalities that were given.

RESULTS: 194 patients were included in the final analysis. There were 74.7% males and 25.3% females patients with mean age of 62.2 14.0. The endoscopists i.e. surgeons and gastroenterologists were equal with no significant difference (54.6% and 45.4% respectively). The endoscopic findings showed more patients with Forrest IIa/IIb compared to Forrest Ia/Ib (61.9% vs 38.1%). However, the majority of these patients received only one endoscopic treatment modality or none at all (79.4%) compared to those receiving two or more treatment modalities. Our findings showed that patients with high stigmata findings of AUNVB only received one treatment modality or none at all (P = 0.045). Furthermore, these findings were also consistently seen in both practices of the surgeons and gastroenterologists. CONCLUSIONS: There was marked variability between the process of care and ‘best practice’ in AUNVB. Certain patient and situational characteristics may influence guideline adherence. Further studies are needed to delineate the underlying causes. Conflict of Interest: None declared.

CONCLUSIONS: Resource and training gaps have been identified using this methodand will inform a planned BSG sponsored visit to Iraq to deliver targeted training on quality assurance, safety and training for endoscopy. Conflict of Interest: None declared.


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P243: AUDIT OF PATIENT COMFORT DURING UNSEDATED DIAGNOSTIC UPPER AND LOWER GASTROINTESTINAL ENDOSCOPY USING MODIFIED GLOUCESTER COMFORT SCORE Srijan Mazumdar, Sridhar Sundaram, Jasmeet Singh Dhingra, Prachi Patil, Shaesta Mehta Tata Memorial Hospital, Department of Digestive Diseases and Clinical Nutrition, Mumbai, India

AIMS: Patient comfort is an important quality indicator in endoscopy. This audit was done to assess the utility of Modified Gloucester Comfort score (GCS) for assessing patient comfort during unsedated diagnostic endoscopy. The Modified Gloucester comfort score has been originally validated for patient comfort during sedated colonoscopy.

METHODS: Between January 2015 and December 2015, patients undergoing diagnostic upper GI endoscopy (UGIE) and complete lower GI endoscopy (Colonoscopy-LGIE) without analgesia, sedation or anaesthesia were assessed for discomfort. UGIE was performed with standard adult endoscopes using 3 puffs, 10% lidocaine spray (10 mg/puff) for pharyngeal anaesthesia. GCS was independently applied by endoscopist (E-GCS) and assisting nurse (N-GCS). GCS 1 GCS 2 GCS 3 GCS 4 GCS 5

No: no discomfort - resting comfortably throughout Minimal: one or two episodes of mild discomfort, well tolerated Mild: more than two episodes of discomfort, adequately tolerated Moderate: significant discomfort, experienced several times during the procedure Severe: extreme discomfort, experienced frequently during the procedure

[Modified Gloucester comfort score]

RESULTS: We analysed 1463 UGIE and 483 complete colonoscopic examinations. Mean procedural time was 10.93 minutes for UGIE and 21.50 minutes for colonoscopy. The median EGCS and N-GCS for both UGIE and LGIE was 2. Endoscopists reported mild discomfort in majority (UGIE-79.6%, LGIE- 74.3%), while severe discomfort was rare (UGIE-0.1%, LGIE-0.6%). Similarly nurses reported mild discomfort in 88.2% and 83.6% in UGIE and LGIE groups, with severe discomfort in only 0.8% in LGIE. There was good inter-observer agreement of E-GCS and N-GCS (Kappa 0.626). Multivariate analysis revealed higher age being associated with lesser discomfort (P = 0.037), but no association with gender in UGIE, while there was no association with age or gender in LGIE group. CONCLUSIONS: Modified GCS is a simple bedside tool to assess patient comfort during unsedated endoscopy with good inter-observer agreeability. The lack of patient reported discomfort is a limitation of this study. Conflict of Interest: None declared.


P244: USE OF DICKINSON AND FISKE GAGGING SEVERITY INDEX IN UNSEDATED UPPER ENDOSCOPY PRACTICE: A PILOT REPORT Sridhar Sundaram, Srijan Mazumdar, Shaesta Mehta, Prachi Patil, Pravir Gambhire Tata Memorial Centre, Department of Digestive Diseases and Clinical Nutrition, Mumbai, India

AIMS: To assess the applicability of the validated Dickinson and Fiske Gagging Severity index (DF-GSI) in endoscopy practice. METHODS: In April 2016, patients with ASA grade I, planned for complete diagnostic UGIE were selected. All patients underwent examination with topical pharyngeal anesthesia alone (3 puffs of 10% Lidocaine spray, 10 mg/puff plus 5 mL of lidocaine gel (20 mg/mL) was applied to the tip of the scope (total dose 130 mg). Intra-procedure severity of gagging was assessed using modified version of validated Dickinson and Fiske Gagging Severity Index (DF-GSI). DF-GSI was independently rated by endoscopist and nurse assistant. Post procedure, patients reported difficulty during swallowing the scope (10 point VAS) and pharyngeal numbness (4 point likert scale).

RESULTS: We applied DF-GSI rating in 31 cases. (19 men, 12 women, mean age 54 years). Education levels included graduates-5, secondary schooling-3 and literate without schooling 22. The endoscopist reported minimal to mild gagging (Grade 1–2) in 24 (77.4%), moderate gagging in 6, and severe in one patient. We found good correlation (kappa value 0.702) between endoscopist and nurse reporting of DF-GSI. Twenty patients (64%) reported mild, 9 (29%) moderate and 2 reported severe difficulty in swallowing the scope. There was no correlation between patient reported difficulty in swallowing the scope and endoscopist reported DF-GSI (P = 0.167). Twenty patients (64.5%) reported mild throat numbness, 7 (22.5%) moderate and 4 (12.9%) lack of throat numbness. There was poor correlation between patient reported numbness and endoscopist rating of DF-GSI scale (P = 0.919). CONCLUSIONS: This pilot study demonstrates the feasibility of using the modified DF-GSI in patients undergoing unsedated UGIE as marker of optimal pharyngeal anesthesia. A larger study is needed to validate the use of DF-GSI in endoscopy practice. Conflict of Interest: None declared.

P245: PATIENT SAFETY AND QUALITY INITIATIVE BY EVALUATING AND IMPROVING THE HANDS-OFF PROCESS AT ENDOSCOPY SUITE IN AKUH Naveen Hirani, Saima Alluddin Alluddin, Rozina Khimani, Endoscopy Suite Aga Khan University Hospital, Endoscopy, Karachi, Pakistan

AIMS: One of the most significant elements of patient care is the handoff. This is the point of time when crucial evidence on


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 the patient´s care is transferred to the patient´s new care provider. At the Aga Khan University Hospital, a quality initiative was untaken with an aim to improve patient safety by means of effective handsoff communication.

METHODS: Juran’s CQI Methodology was used to carry out improvement. Need was identified as the result of a sentinel event, the root cause of which was found to be ineffective handsoff communication. A multidisciplinary team was formulated including representatives from medical, para-medical and administrative management. Next, brain storming session was conducting to identify causes of the communication breakdown. Those causes were then plotted on fish bone diagram and pareto analysis was conducted. Vital few causes included lack of hands off tool and gaps in knowledge. As a remedy, a customized “Endoscopy Hands-Off Communication Checklist” was made, following the SBAR (Situation, Background, Assessment, Recommendations) standard. In the first phase, nursing staff of the endoscopy suite was educated about significance of process and utilization of checklist. Same training sessions were later conducted with nursing staff of other medicine and surgical units.

RESULTS: By the end of the project, 100% of endoscopy nursing staff and 98.6% of nursing staff from other med-surg areas were trained. The checklist was successfully implemented in October, 2014 and a compliance of 96.4% and 99.2% was maintained until ends if 2014 and 2015 respectively. Sustainability is assured by monitoring clinical indicator entitled “Safe Transportation of patient from ward to Endoscopy Suite.” In addition to this, zero related sentinel event has been reported so far.


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undergoing diagnostic endoscopic ultrasound (EUS) performed under endoscopist directed sedation (EDS). A combination of IV midazolam and fentanyl was used to achieve the desired level of mild- moderate sedation. Sedation level was scored using the validated Modified Richmond Agitation -Sedation Score. Endoscopist, nurse and patients reported the comfort score using the validated Modified Gloucester Comfort Scale (M-GCS).

RESULTS: A total of 109 EUS procedures were performed. Twenty patients were excluded (14 were under GA, 6 EUS combined with ERCP). Of the 89 patients analysed (M:F - 45:44, mean age - 51.7 years, mean weight-54 kgs) had co-morbidity status of ASA risk I (62%), ECOG 1 (100%), SGA B (93%). 78 % had pre procedure apprehension. Median doses of IV Midazolam and Fentanyl used were 3 mg and 50 Ug respectively. Median time to achieve desired sedation level was 5 minutes. Median procedure duration was 16 minutes. There was no discomfort (M-GCS-1) in 85.4%, 88.8% and 91% as reported by patient, nurse and endoscopist respectively. There was good concordance between endoscopist and nurse scores (Kappa 0.4, P < 0.005) and also with patient reported scores (P = 0.001) between both endoscopist (Kappa = 0.3) and nurse (Kappa = 0.3). Endoscopist reported satisfaction for performance of procedure in 97% correlating well with E-GCS (P < 0.005). CONCLUSIONS: Modified GCS is a quick bedside tool to assess patient comfort, a quality indicator in endoscopy practice, during diagnostic EUS performed under mild to moderate sedation with good correlation between endoscopist patient and nurse reported scores. Conflict of Interest: None declared.

CONCLUSIONS: Implementation of the handoff program was associated with cutbacks in unsafe practices in patient safety and in avoidable adverse events, without a negative effect on workflow. Conflict of Interest: None declared.

P246: CONCORDANCE BETWEEN COMFORT SCORING BY PATIENT, ENDOSCOPIST AND NURSE USING MODIFIED GLOUCESTER COMFORT SCORE IN PATIENTS UNDERGOING ENDOSCOPIC ULTRASOUND UNDER ENDOSCOPIST DIRECTED SEDATION Jasmeet Singh Dhingra, Shaesta Mehta, Prachi Patil Tata Memorial Hospital, Digestive Diseases and Clinical Nutrition, Mumbai, India

AIMS: To assess the concordance of patient, endoscopist and nurse reported comfort scoring using the Modified Gloucester Comfort Scale in patients undergoing endoscopic ultrasound under endoscopist directed sedation. METHODS: Between Jan 2015 and August 2016, comfort

P247: THE CONVERSION OF PLANNED COLONOSCOPY TO SIGMOIDOSCOPY AND THE EFFECT ON THE MEASUREMENT OF QUALITY INDICATORS Sabina Beg1, Stefano Sansone1, John Schembri2, Jay Patel3, Mo Thoufeeq2, Gareth Corbett3, Krish Ragunath1 1

Nottingham University Hospital, Gastroenterology, Nottingham, 2Sheffield Teaching Hospital, Gastroenterology, Sheffiled, and 3Cambridge University Hospital, Gastroenterology, Cambridge, UK

AIMS: A caecal intubation rate of >90% is a well-accepted quality indicator of colonoscopy and is monitored within endoscopy units. Endoscopists´ desire to meet this target may mean that incomplete colonoscopies are recorded as flexible-sigmoidoscopies. The aim of this study was to examine whether this is a clinically significant phenomenon.

METHODS: A retrospective review of all flexible-sigmoidoscopies performed between 1st January 2015 and 31st December 2015 at Nottingham University Hospitals, Sheffield Teaching Hospitals and Cambridge University was performed. Where a colonoscopy was requested but a flexible-sigmoidoscopy

during endoscopy was prospectively recorded in patients


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performed, the patient´s records and endoscopy reports were reviewed.

RESULTS: 6839 flexible-sigmoidoscopies were performed by 125 endoscopists. 149 requests could not be retrieved and were excluded from this analysis. Of the 6690 sigmoidoscopy requests reviewed, 2.8% (n = 190) procedures were originally requested as a colonoscopy. 32 were deemed clinically inappropriate and were converted prior to commencing the procedure. 53 of converted procedures were planned polypectomies or post polypectomy assessments where only a limited examination was required. 105 conversions occurred in patients who had a valid documented indication for colonoscopy and had undergone full bowel preparation. The most common reasons cited included poor bowel preparation (n = 38), technically challenging (n = 30) or converted at the endoscopists discretion (n = 26). A clear reason was not apparent in 11 cases. During the study 21271 colonoscopies were performed, inappropriate conversions represented 0.45% of the total requests. This practice was observed amongst 41 endoscopists. When inappropriate conversions were included in individuals’ performance data, 6 endoscopists fell to ≤90% target caecal intubation target. CONCLUSIONS: A small, but significant number of colonoscopies are converted to flexible-sigmoidoscopies at the time of the procedure. This study demonstrates the conversion of colonoscopy as being a potential limitation of relying on caecal intubation rate. Endoscopy units should consider monitoring the rate of inappropriate conversions to ensure quality is maintained. Conflict of Interest: None declared.

P248: SAFETY AND EFFECTIVENESS OF ENDOSCOPIC SUBMUCOSAL DISSECTION UNDER GENERAL ANESTHESIA FOR ELDERLY PATIENTSΔ 1

METHODS: A retrospective review was performed for 219 consecutive patients who underwent ESD under general anesthesia for neoplasms of the stomach, esophagus, and colorectum at our institution between May 2010 and December 2014. The patients were classified into two group: (A) those older and (B) those younger than 75 years. Age, preoperative comorbidities, and treatment outcomes, including duration of hospitalization and occurrence of complications, were compared between groups using chi-square and Student t-tests.

RESULTS: There were 77 patients in group A and 142 in group B. The median age was 79.6 3.6 years (range, 75–89 years) for group A and 63.9 8.2 years (range, 26–74 years) for group B. Group A had significantly more preoperative comorbidities than group B (93.5% vs 71.1%; P < 0.001). There were no statistical group differences for median operation time, mean hospitalization, or occurrence of complications. No perioperative mortality or major postoperative complications including aspiration pneumonia occurred. CONCLUSIONS: Although the elderly patients in our study had preoperative comorbidities, they achieved similar results to the younger patients, with similar rates of perioperative complications. With the cooperation of an anesthesiologist, ESD under general anesthesia is a safe and effective treatment for both older and younger patients. Conflict of Interest: None declared.

P249: UNSEDATED OESOPHAGOGASTRODUODENOSCOPY - A RANDOMISED CONTROLLED TRIAL TO ASSESS AND COMPARE PATIENT PREFERENCE AND TOLERABILITY OF TRANSNASAL VS SMALL CALIBER PER-ORAL VS CONVENTIONAL APPROACH

CLINICAL ENDOSCOPIC PRACTICEENDOSCOPY: SEDATION

1

anesthesiologist. The aim of this study was to review the safety and effectiveness of ESD under general anesthesia for elderly patients by comparing results from older and younger patients.

1

Kanefumi Yamashita , Hironari Shiwaku , Matsuoka Taisuke , Toshihiro Ohmiya1, Hiroki Okada1, Satoshi Nimura2, Ken Yamaura3, Suguru Hasegawa1 1 Fukuoka University Faculty of Medicine, Department of Gastroenterological Surgery, 2Fukuoka University Faculty of Medicine, Department of Pathology, and 3Fukuoka University Faculty of Medicine, Department of Anesthesiology, Fukuoka, Japan

AIMS: The proportion of elderly persons in Japan is 25%, a rate that has been increasing every year. Accordingly, the cases of Endoscopic submucosal dissection (ESD) for elderly patients are increasing. ESD is usually performed under conscious sedation. However, it is associated with some issues, including patient movement because of insufficient effect of sedation and a risk of aspiration pneumonia. Therefore, we perform ESD under general anesthesia with endotracheal intubation by an

Alexander Huelsen1,2,3, Ratna Pandey2, Lifeng Zhou4, Imran M Khan2, Ali Jafer2, Russell S. Walmsley2 1

School of Medicine, University of Queensland, Brisbane, Australia, 2North Shore Hospital, WDHB, Gastroenterology Department, Auckland, New Zealand, 3Princess Alexandra Hospital, Gastroenterology & Hepatology Department, Brisbane, Australia and 4WDHB, Planning, Funding and Outcomes Unit, Auckland, New Zealand

AIMS: Unsedated outpatient oesphagogastroduodenoscopies (OGDs) avoid sedation related complications, reduce appointment time and endoscopy unit staffing requirements and patients can drive and work the same day. OGDs can be performed in three ways: using small caliber endoscopes either trans-nasally (TN) or per-orally (SC-PO) or conventional size (conv) endoscopes per-orally. Tolerability without sedation however remains a concern and patient preference is not well


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 established. We therefore aimed to assess patient preference and tolerability in a randomised controlled trial.

METHODS: Volunteers underwent all variants without sedation within ≤14 days and graded tolerability following each procedure. After all variants participants determined a preference ranking.

RESULTS: 40 participants (29 female) underwent all three OGD variants unsedated. Average age was 43 years (range 22–62). Of overall 120 procedures performed 113 (94.2%) were tolerated and seven procedures (5.8%) in six participants had to be aborted due to pain on insertion (TN, n = 1), gagging (SC-PO, n = 4 and conv n = 1) or tight nasal passage (TN, n = 1). TN caused a higher pain score during insertion compared to SC-PO (P < 0.001) and conventional approach (P < 0.047), however pain during the procedure was minimal and comparable. Gagging and nausea was significantly less during TN compared to SC-PO (P ≤ 0.01) or conventional approach (P < 0.001). Participant’s preference was assessed and 42% preferred the SC-PO approach the most, 36% the TN and 22% the conventional approach, however the differences in overall tolerability between the groups were not statistically significant. 90% of the participants would prefer an unsedated OGD in the future.


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METHODS: A total of 128 patients undergoing endoscopic ultrasound were randomized to receive either etomidate or propofol blinded administered by a registered nurse. Endpoints comprised cardiopulmonary adverse events, efficacy, patient satisfaction, and sedation profiles.

RESULTS: The incidence of oxygen desaturation (4/64 [6.25%] vs 20/64 [31.25%], P = 0.001) and respiratory depression (5/64 [7.81%] vs 21/64 [32.81%], P = 0.001) was significantly lower in the etomidate group than in the propofol group. All cardiovascular episodes were self-limited, controlled completely without special intervention, and lacked significant difference between both groups. The frequency of myoclonus was significantly higher in the etomidate group (22/64 [34.37%]) compared with the propofol group (8/64 [12.50%]) (P = 0.012). Repeated measure analysis of variance revealed significant effects of sedation group and time on systolic blood pressure (etomidate group > propofol group). Physician satisfaction was greater in the etomidate group than in the propofol group. CONCLUSIONS: Etomidate administration resulted in fewer respiratory depression events and had a better sedative efficacy than propofol; however, it was more frequently associated with myoclonus and increased blood pressure during endoscopic procedures. Conflict of Interest: None declared.

CONCLUSIONS: Our study was unable to identify a single best-tolerated unsedated OGD variant. The TN approach caused more discomfort during insertion, however significantly less gagging and nausea. The conventional approach was the least favoured however differences were statistically not significant. Only 10% of our participants would prefer sedation should they require an OGD in the future. Conflict of Interest: None declared.

P251: A PROSPECTIVE STUDY OF EFFICACY, SAFETY AND COMFORT OF ‘ENDOSCOPIST DIRECTED SEDATION’ FOR ERCP USING MIDAZOLAM AND FENTANYL IN MALIGNANT OBSTRUCTIVE JAUNDICE Shaesta Mehta, Mukund Virpariya, Prachi Patil, Jasmeet Singh Dhingra

P250: ETOMIDATE VS PROPOFOL ADMINISTRATION FOR SAFE SEDATION DURING ENDOSCOPIC ULTRASONOGRAPHIC PROCEDURES: A PROSPECTIVE DOUBLE-BLINDED RANDOMIZED CONTROLLED TRIAL Sea Hyub Kae Hallym University Dongtan Sacred Heart Hospital, Internal Medicine, Hwaseong, Korea

AIMS: Although a growing body of evidence demonstrates that propofol-induced deep sedation can be effective and performed safely, cardiopulmonary adverse events have been frequently observed. Etomidate is a new emerging drug that provides hemodynamic and respiratory stability, even in highrisk patient groups. The objective of this study was to compare safety and efficacy profiles of etomidate and propofol for endoscopic sedation.

Tata Memorial Centre, Digestive Diseases and Clinical Nutrition, Mumbai, India

AIMS: Prospective audit of “endoscopist directed sedation” (EDS) using midazolam and fentanyl for ERCP in malignant obstructive jaundice. METHODS: Between January 2015 and March 2016, EDS used for ERCP and biliary drainage was analysed. We planned to perform ERCP under mild - moderate sedation using a combination of IV midazolam and IV fentanyl. Validated outcome assessment scales used included Richmond Agitation-Sedation Score for sedation, Aldrete score for recovery and Gloucester Comfort Scores reported by endoscopist, nurse and patients.

RESULTS: Between Jan 2015-March 2016, 334 underwent ERCP. Thirty-three cases ASA ≥3, ECOG ≥3, expected procedure duration ≥1 h referred for GA) were excluded. 301 cases received EDS, 7 were excluded for incomplete data and 294 were analysed (men 161, women 133, mean age 54.1 years, mean weight 52.5 kg). Co-morbid status included ASA risk I (75%), ECOG 1 (98%), SGA B (98%). Start up midazolam and


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fentanyl dose was 3 mg in 94% (1–5 mg) and 50 μg in 76% (25– 100 Ug). Desired sedation at intubation was achieved in 292 (mild to moderate in 276 patients (93.9%) and deep in 16 (5.4%), within a median of 6 minutes. Median procedure duration was 25 minutes. Median total doses of midazolam and fentanyl required to maintain sedation was 3 mg and 50 μg respectively. 91.8% patients reported no discomfort at intubation correlating well with sedation levels at intubation (P < 0.005). Intraprocedure discomfort was reported by 32.7%. E-GCS, NGCS and P-GCS achieved significant correlation at intubation and intraprocedure (Kappa 0.4 and 0.5, P < 0.005). Sedation related morbidity occurred in 8 (transient hypotension or hypoxia-6, midazolam associated restlessness-1, serious aspiration-1) without any mortality. Median Aldrete score was 10. Endoscopist satisfaction for performance of procedure was reported in 93.5% correlating with E-GCS (P < 0.005).

CONCLUSIONS: Midazolam with fentanyl is a safe effective and comfortable EDS protocol. Conflict of Interest: None declared.

CLINICAL ENDOSCOPIC PRACTICE: ENDOSCOPY: TRAINING AND EDUCATION P252V: TELEMEDICINE FOR GASTROINTESTINAL ENDOSCOPY - THE ENDOSCOPIC CLUB ECONFERENCE IN THE ASIA PACIFIC REGION Shiaw-Hooi Ho1, Rungsun Rerknimitr2, Kuriko Kudo3, Shunta Tomimatsu3, Mohamad Zahir Ahmad4, Akira Aso5, Dong-Wan Seo6, Khean-Lee Goh1, Shuji Shimizu7 1

University of Malaya, Department of Medicine, Kuala Lumpur, Malaysia, 2Chulalongkorn University, Department of Medicine, Bangkok, Thailand, 3Kyushu University Hospital, Telemedicine Development Center, Fukuoka, Japan, 4 University of Malaya Medical Centre, Department of Information Technology, Kuala Lumpur, Malaysia, 5Kyushu University Hospital, Medicine and Bioregulatory Science, Fukuoka, Japan, 6Asan Medical Center, University of Ulsan College of Medicine, Department of Gastroenterology, Seoul, Korea and 7Kyushu University Hospital, Department of Endoscopic Diagnostic and Therapeutic, Fukuoka, Japan

AIMS: Endoscopic Club E-conference (ECE) was set up in May 2014 to cater for the increased demand of gastrointestinal endoscopy-related teleconferences in the Asia-Pacific region. This study described the running of ECE meeting, examined the group dynamics, outlined members’ feedback and analyzed factors affecting participation enthusiasm. It is hoped that the findings here can serve as guidance for future development of other teleconference groups.

During meeting, alternative communication is established concurrently among the engineers for troubleshooting. Country’s economic situation, time zone difference, connectivity with research and education network (REN) and engineering cooperation of each member were described and analyzed with regards to their association with participation enthusiasm which was taken as participation of at least 50% of the meetings since their joining in. Association between these factors were calculated using two-way table with chi-square test to generate odds ratio and P-value.

RESULTS: Till May 2016, ECE members increased by 314% (from 7 to 29). Sixty-two percent of the members were from Southeast-Asia and East-Asia region. Ten ECE meetings were held and 51 presentations were made. Feedback received indicated high level of satisfaction for program content, audiovisual transmission and ease of technical preparation. Upper gastrointestinal luminal endoscopy-related topics (35%) was the most favourite program content. They were mainly presented in case presentation style (86%) with focus on management challenges (53%). Time zone difference of more than 6 h and poor engineering cooperation were independently associated with inactive participation (P = 0.04 and P = 0.001 respectively). CONCLUSIONS: Good program content and high quality audio-visual transmission are keys to the success of a medical teleconference. In our analysis, poor engineering cooperation and huge time zone difference contributed to inactive participation. Conflict of Interest: None declared.

P253: UNDERSTANDING THE SCIENCE OF EDUCATION IN ENDOSCOPY TRAINING Neel Sharma1,2, Khek Yu Ho1 1

National University Hospital, Singapore, Singapore, Harvard Macy Institute, Boston, USA

2

AIMS: Medical education is now a recognised academic discipline. However gastroenterology as a field has been slow to catch up. Currently we read countless papers highlighting the slow rates of competency gain among GI trainees. And their mentors often question why. The simple answer is a lack of understanding of the science of education. This talk aims to highlight the movements in medical education in terms of how to achieve a competent learner and assess them accordingly. We need to move the field forward and by opening ourselves to medical education can we aim to do so. METHODS: N/A.

METHODS: Vidyo teleconference system was used. Twice

RESULTS: N/A.

technical test sessions were conducted among the engineers prior to the meeting. A total time of 90 10-minute is allotted for each meeting and around 8-minute for each presentation.

CONCLUSIONS: N/A. Conflict of Interest: None declared.



P254: AN EVALUATION OF COST AWARENESS IN GASTROINTESTINAL ENDOSCOPY♦ Sabina Beg1, Tyara Banerjee2 1

Nottingham University Hospital, Gastroenterology, Nottingham, and 2Cambridge University Hospitals, Gastroenterology, Cambridge, UK


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P255: EQUIPMENT INSTALLATION FOR COLOSCOPY, A FIRST STEP TOWARDS QUALITY: RESULT OF THE FLASH 6 NATIONAL SURVEY Jean Christophe Letard1, Isabelle Ingrand2, Vianna Costil3, Pierre Dalbies4, Pierre Ingrand5, Jean Lapuelle6, Jean Marc Canard3, Denis Sautereau7 1

Polyclinique de Poitiers, Poitiers, 2INSERM 1402, Poitiers, CREGG, Endoscopy, Paris, 4CREGG, Endoscopy, Beziers, 5 INSERM 1402, Statistic, Poitiers, 6CREGG, Endoscopy, Toulouse, and 7CHU Dupuytren, Gastroenterology, Limoges, France 3

AIMS: With increasing financial strain on health systems it is important that limited budgets spent optimally with both quality and cost of care in mind. In the UK where healthcare is funded by taxation clinicians are not held accountable for the cost of treatment. It is unknown whether endoscopists have costawareness of the equipment they use and whether increased awareness would affect choices. METHODS: An anonymous web-based survey was designed, where participants were asked to estimate the cost of seven commonly used endoscopy accessories. Endoscopists and endoscopy nurses within the East of England and East Midlands deaneries were invited to participate, between DecemberFeburary 2016. The cost of equipment was established by obtaining the highest and lowest tariff paid by the hospitals and the manufacturer list price. A price estimate was classed as correct if it lay within the pre-established price range. A Likert Scale was completed to ascertain the influence of price on equipment choice.

AIMS: This national survey of the equipment installation for coloscopy was initiated by the CREGG and the Institute for Training and Research in Digestive Endoscopy (IFRED) in order to assess practices in France in 2015. METHODS: French HGE received from June to December 2015 a short questionnaires with 4 possible equipment installation (A/ B/C/D). The responding HGEs were split into 3 groups (G 1: HGE experts/teachers at IFRED; G 2: senior HGEs and G 3: HE interns at University Hospitals). The 4 installation possibilities were grouped arbitrarily to an “optimal” position (A/C no crosscabling between generator and scope, view along the axis of the scope, free space in front of the patient) or a “non-optimal” position (B/D cross-cabling between generator and scope, view perpendicular to the axis of the scope, no free space in front of the patient). To confirm the results, we made an exhaustive analysis of the WEB images (Google) used for teaching (key words: coloscopy, colonoscopy, colonoscopy installation, performing a colonoscopy, colonoscopy technique (G 4)).

RESULTS: 96 individuals completed this survey, of which 23 responses were incomplete and excluded from analysis. The 73 valid responses were completed by 22 consultants, 16 nurses and 35 trainees. The respondents had an average of 8 years (range: 1–28) of endoscopy experience. Accurate estimates were observed in 24.7% (CI 95% 14.8–34.6) 10 mm snare, 46.6% (CI95% 35.2–58.0) haemostatic powder system, 61.6% (CI95% 50.4–72.8) disposable net, 43.8% (CI95% 32.4–55.2) colonoscopy injection needle, 38.4% (CI95% 27.2–49.6) single use clip, 16.4% (CI95% 7.9–24.9) standard cold biopsy forceps and 32.9% (CI95% 22.1–43.7) 6-shooter variceal-band ligator system. Consultants were observed to be the poorest predictors of price, despite having the greatest duration of experience.

RESULTS: 201 HGEs answered: G 1: 25; G 2: 114 and G 3: 62. When the 4 possible installations (A, B, C, D) were grouped into positions A/C or B/D, a significant difference was noted (P < 0.0001) for the installation of “optimal” equipment between G 1 (77.8% of A/C positions) and G2, G3 (30.2%, 32.3% of A/C positions). The analysis of WEB images (G 4) noted 73.3% A/C positions with a significant difference on comparing G 2, G 3 (P < 0.0001).

CONCLUSIONS: This study has highlighted poor knowledge

CONCLUSIONS: This national survey of the installation of

amongst endoscopy users. Of the 7 equipment items, only the cost of a snare was estimated correctly by over 50% of participants. Individuals reported that price had little influence on their clinical practice. Conflict of Interest: None declared.

equipment shows a statistically significant difference between HGE experts/teachers and senior HGEs or HGE interns relative to the installation of equipment for performing coloscopies (P < 0.0001), these results seeming to be confirmed by the analysis of WEB image data for teaching purposes. Conflict of Interest: None declared.


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P256: HANDS-ON TRAINING ON PORCINE MODELS FOR ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) AND PER-ORAL ENDOSCOPIC MYOTOMY (POEM) DOES IT HELP TRAINING OF PHYSICIANS FOR THESE ADVANCED PROCEDURES? 1

1

1

Mahesh Mahadik , Amol Bapaye , Nachiket Dubale , Viral Vyas1, Shivangi Dorwat1, Pankaj Desai2 1 Deenanath Mangeshkar Hospital, Shivanand Desai Center For Digestive Disorders, Pune, and 2Surat Institute of Digestive Sciences, Surat, India

AIMS: Expertise in procedures like endoscopic submucosal dissection (ESD) and per-oral endoscopic myotomy (POEM) is limited to few select centers and training has been difficult. We developed a special fresh cadaver porcine model for ESD and POEM training at our center. During a 12-month period, four hands-on training workshops were conducted. This study aims to evaluate the impact of this training program.

METHODS: 116 participants enrolled for 2-day ESD/POEM workshops completed a feedback form. Each physician was contacted after 8-months for a survey - whether any procedures had been initiated, reasons for non-initiation, type and number of procedures performed, difficulties faced, need for additional training.

RESULTS: 102 responded via feedback form and were inclined to perform these procedures within 6-months. Of these, 88 participants (75.8%) could be contacted for the post workshop telephonic survey. 23/88 (26.1%) confirmed having attempted and 22/88 (25%) successfully performed either ESD or POEM within 6-months. ESD was performed by 15 (17%), POEM by 4 (4.5%) and both ESD & POEM by 3 (3.4%) physicians. No significant adverse events were reported. Amongst 65 who did not initiate any procedure, 40 (61.5%) cited lack of instrumentation and infrastructure as the reason, 9 (13.8%) mentioned lack of suitable patients and 12 (18.4%) requested additional training. CONCLUSIONS: Current study shows significant impact of hands on training models with 25% participants initiating ESD and POEM. Such workshops may serve as an important platform for aspiring endoscopists to train in these advanced procedures. Conflict of Interest: None declared.

P257: VIDEO-BASED SUPERVISION FOR TRAINING OF ESD. AN INTERNATIONAL COLLABORATION STUDYΔ Seiichiro Abe1, Amit Bhatt2, Arthi Kumaravel2, Ichiro Oda1, John Vargo2, Yutaka Saito1 1

National Cancer Center Hospital, Endoscopy Division, Tokyo, Japan and 2Cleveland Clinic, Gastroenterology and Hepatology, Cleveland, USA

AIMS: While porcine model training is commonly used for learning ESD, there are limited Western ESD experts to supervise training. We aimed to assess the value of a videobased remote supervision for ESD training. METHODS: Two Western endoscopists who had no prior experience of ESD performed training procedures in an ex-vivo porcine stomach. A Japanese ESD expert analyzed the training videos, scored them, and gave written feedback for improvement after each training session. Competency was defined as consistent en-bloc resection of 3 cm area within 30 minutes, and without perforation.

RESULTS: Endoscopists 1 (attending, FASGE) and 2 (gastroenterology fellow) reached competency at 23 and 25 procedures, respectively. No difference in skill improvement between the two endoscopists was noted.

Time to completion (min), median[IQR] En bloc resection, n (%) Perforation, n (%) Completed in 21 (N = 15)

P-value

60.0 [51.0, 65.0]

36.5 [31.5, 45.0]

28.0 [19.0, 33.0]

0.01) and OC (P = 0.01), and was significantly less in LC (P = 0.01).

CONCLUSIONS: According to this study, minor injuries, managed solely with stenting are the commonest type of IBDI. However, major injuries still account for almost half of IBDI. Incidence of major injuries does not appear to have reduced by conversion, indicating that the injury occurred prior to conversion. The significant association of need for reconstruction with OC, probably reflects the case selection. Conflict of Interest: None declared.

P273: FORMATION OF SLUDGE, PLUG OR STONES IN A REMNANT INTRAPANCREATIC CHOLEDOCHAL CYST: A CASE SERIES Seon Mee Park1, Eun Bee Kim1, Joung-Ho Han1, Jae-Woon Choi2 Chungbuk National University Hospital 1Internal Medicine, and 2General Surgery, Cheongju, Korea

AIMS: Incomplete resection of a choledochal cyst when the cystic lesion extends deeply into the pancreas makes protein plug/stone formation, pancreatitis, and cholangiocarcinoma. METHODS: We experience three cases of choledocholithiasis in a remnant intrapancreatic choledochal cyst presented with epigastric pain and pancreatitis.

RESULTS: A 23-year-old woman who had excision of choledochal cyst in neonate, came to us with epigastric pain. Abdominal CT scan showed stones inside remnant cyst in pancreas. Whitish hard round stones were removed with ERCP and she improved. A 34-year-old woman who underwent cyst excision three years ago presented with pancreatitis. Abdominal CT revealed radiolucent plug inside remnant cyst in pancreas. Whitish soft plug was removed with ERCP and pancreatitis improved. A 26-year-old woman who received cyst excision two months ago presented with epigastric pain. Whitish sludge and whitish amylase rich fluid were drained from the remnant cyst with ERCP and she improved. We report three cases of sludge, plug, or stones in the remnant intrapancreatic choledochal cysts, who received operations before 23 years, 3 years, and 2 months, respectively. CONCLUSIONS: We suggested the formation of sludge, plug, and stone in remnant intrapancreatic choledochal cysts by the reflux of pancreatic juice depending on relapsing time after surgery. Conflict of Interest: None declared.


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P274: ENDOSCOPIC APPROACH IN DIAGNOSTICS AND TREATMENT OF MALIGN TUMORS OF PAPILLA VATERI (PV) Paul Barbado1, Aleksey Balalykin2 1

Narofominsk State Hospital, Surgery, Naro Fominsk, and Central Military Hospital, Moscow, Russia

2

AIMS: Diagnostics of malign tumors of PV and endoscopic approach in it‘s treatment are alternative to classical surgery but still questionable. Aim of study is evaluation of minimally invasive methods in diagnostics and treatment of malign tumors of PV. METHODS: From 2004 to 2011, 1021 patients undergone diagnostics, 51 of them suspicious on malign tumor of PV included in study. All patients undergone transabdominal sonography, endoscopy, endosonography, CT, MRI, ERCP.

RESULTS: In 11 (20.6%) cases tumor was rated as T1, T2 was in 24 (47%), T3 in 16 (32.4%) cases. Histologically we found adenocarcinomas 19 (37.2%), carcinoid tumours 1 (2%), adenomas with high-grade dysplasia 31 (60.8%). Indications for papillectomy based mostly on ultrasonogrphical data - type of growth, presence of lymphadenopatia, condition of muscular layer and terminal part of pancreatic an common bile duct. In 12 patients with small tumors, including 1 with carcinoid, snare en bloc excision was perform. In other 39 complex approach was perform. Complex approach included: ERCP, papillothomy 100% (39 patients), piecemeal resection 56.8% (29), argon plasma destruction 30.8%(12), electrocoagulation 25.6% (10). Plasma destruction and coagulation of benign and malign tumors performed in 56.4% (22 patients) after piecemeal excision or by itself in small tumors and required stenting of pancreatic duct in 12.8%(5 patients), bile duct in 25.6% (10 patients) and both of it in 22.6% (7 cases). Operations complicated with acute pancreatitis in 2 cases (3.9%). All patients have been put under endoscopic, endosonographic, CT surveillance in 3-6-12 months. In 3 patients (5.8%) we found recurrence of disease. Ultrasonography was most important method in follow-up surveilance. CONCLUSIONS: Endoscopic papillectomy can be performed in: 1. patients with carcinoma of PV associated with high operation risk and absence of metastasis; 2. Carcinoid of papilla; 3. Benign tumors. Thorough indications, technical principles and follow-up must be provided. Conflict of Interest: None declared.


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P275: RESOLUTION OF INTRABILIARY RUPTURED HEPATIC HYDATID CYST AFTER ENDOSCOPIC EXTRACTION: A CASE REPORT Ashraf Mubarak Minia University, General Surgery, Minia, Egypt

AIMS: Hepatic hydatid cyst may rupture into bile ducts in 4– 20% of cases leading to cholestasis in 2/3 of cases. We tried to prove that ERCP can replace surgery in treatment of intrabiliary ruptured hydatid cyst. METHODS: Our patient was 42 years old male with cholestasis, abdominal ultrasonography showed hypoechoic lesion at postero-inferior aspect of right lobe related to dilated CBD, total bilirubin 26.1 mg/dL, direct bilirubin 18.8 mg/dL. MDCT revealed ovoid cystic lesion in right lobe, serology for hydatid was positive. Cyst was seen communicating with confluence of hepatic ducts. During ERCP, membranes were seen coming out of papilla of Vater, on injection of contrast; communication of biliary tree with cyst was established. Endoscopic papillotomy was performed and cannulation of bile duct reached abscess cavity with aspiration of yellowish green fluid, bacteriological examination of this fluid showed pseudomonas aeruginosa. Large amount of membranes were removed from CBD and sent for histopathology which showed picture of hydatid cyst. Procedure was completed with CBD stenting. Single course of Albendazole was given. Follow up after one month showed marked improvement of patient´s general condition with drop of TLC and bilirubin.

RESULTS: Follow up MDCT showed marked regression in size of previously described lesion. One month later, additional drop of bilirubin was achieved. Abdominal ultrasonography showed complete resolution of cyst confirmed by ERCP revealing start of cyst calcification with obliteration of its cavity and stent was removed. CONCLUSIONS: We concluded that therapeutic ERCP should replace surgery in treatment of intrabiliary rupture of hepatic hydatid cyst. Conflict of Interest: None declared.

P276: OUTCOME OF REPEAT ERCP AFTER FAILED INITIAL NEEDLE KNIFE SPHINCTEROTOMY FOR BILIARY CANNULATION Hiroyuki Hisai, Tamaki Sakurai, Yutaka Koshiba, Yusuke Kanari, Natsumi Yamauchi Japanese Red Cross Date General Hospital, Department of Gastroenterology, Date, Japan

AIMS: Needle knife sphincterotomy (NKS) is often used as the last resort for facilitating biliary cannulation. The aim of this study was to assess the outcome of repeat ERCP after failure with NKS for selective biliary access.

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 METHODS: Retrospective analysis of all patients who underwent initial biliary cannulation after use of NKS between September 2000 and August 2016. Success was defined as deep placement of a catheter into the common bile duct.

RESULTS: One hundred and seventy-six patients were identified. Eighty-five patients (48.3%) underwent prior placement of a pancreatic stent. Selective biliary cannulation was successful after the initial NKS in 116 patients (65.9%), during a second ERCP in 50 including additional NKS in 4 (28.4%), in a third ERCP in 3 (1.7%), and in a fourth ERCP in 1 (0.6%), achieving a total cannulation rate of 96.6% (170 of 176). The median time to repeat ERCP was 1 days (range 1–13 days). Of 60 patients, common causes of failed initial NKS were biliary deep cannulation failure in 52 (86.7%) and blocking of the endoscopic view due to bleeding in 8 (13.3%). The success rate of the second ERCP after one day was significantly lower than that of more than 2 days later (82.3% vs 100%, P = 0.032). Seventeen complications (9.7%) occurred in 16 (9.1%) patients (pancreatitis in 12, bleeding in 4) after initial NKS, and moderate perforation developed in 1 after second ERCP. The use of a pancreatic stent was not related to complication rate. There was no procedurerelated mortality, and all complications were resolved by conservative management. CONCLUSIONS: Repeat ERCP after failed initial NKS for biliary access is safe and effective in the majority of cases. It is more worthwhile repeating ERCP if the patient’s clinical condition permits. Conflict of Interest: None declared.

P277: FACTORS INFLUENCING THE SUCCESS OF BILIARY CANNULATION WITH ERCP PERFORMED BY TRAINEESΔ Takayuki Tsujikawa, Shinpei Doi, Katsunori Sekine, Matoshi Mabuchi, Ichiro Yasuda Teikyo University School of Medicine University Mizonokuchi Hospital, Department of Gastroenterology, Kawasaki, Japan

AIMS: Efficient training is required for the endoscopic retrograde cholangiopancreatography (ERCP) procedure, with consideration of safety. In this study, we retrospectively evaluated the factors that influence the success of bile duct cannulation with ERCP performed by trainees. METHODS: A trainee was defined as an endoscopist with less than 5 years of experience performing the ERCP procedure. Trainees performed ERCP for the first 15 minutes of the operation, and if bile duct cannulation was unsuccessful, a senior doctor replaced the trainee.

RESULTS: The study included 108 patients (61 male and 47 female patients) between April 2014 and February 2015. The mean patient age was 70.5 (29–93) years. The papilla classification was as follows: nodular type, 66 patients (61.1%); onion-like type, 22 (20.4%); slit type, 8 (7.4%); separated opening type, 6 (5.6%); and others, 5 (4.6%). Trainees


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 successfully performed bile duct cannulation in 85 patients (78.7%), and among these patients, the primary procedure was combined with the pancreatic duct guide wire technique in 8 patients (9.4%). The final success rate of bile duct cannulation was 99.0% (107 cases), including replacement of a trainee with a senior doctor. The factors associated with the success of bile duct cannulation by a trainee were periampullary diverticulum (P = 0.03 [odds ratio, 2.79]) and intraoperative intestinal peristalsis (P = 0.01 [10.67]) in univariate analysis, and intraoperative intestinal peristalsis (P = 0.01 [10.0]) in multivariate analysis.

CONCLUSIONS: It is necessary to consider the antispasmodic state during ERCP performed by a trainee for bile duct cannulation. Conflict of Interest: None declared.


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fibrillation. Overall 6 (4.5%) patients died during in-hospital stay, out of which 4 died due to post-ERCP complications and 2 died due to cirrhosis related causes.

CONCLUSIONS: ERCP in patients with cirrhosis can be performed with safely, though it carries a higher risk for morbidity and mortality than general population. Conflict of Interest: None declared.

P279: ENDOSCOPIC GALL BLADDER STENTING FOR ACUTE CHOLECYSTITIS Roy J. Mukkada, Mathews J. Chooracken, Jose Francis, Antony P. Chettupuzha, Pradeep G. Mathew, Shelly C. Paul, S. Ramakrishna, Abraham Koshy VPS Lakeshore Hospital, Gastroenterology, Kochi, India

P278: SAFETY AND EFFICACY OF ERCP IN PATIENTS WITH CIRRHOSIS Nitin Jagtap1, Manu Tandon1, Mithun Sharma1, Rajesh Gupta1, Sundeep Lakhtakia1, Mohan Ramchandani1, Rakesh Kalapala1, G. V. Rao2, D. Nageshwar Reddy1 Asian Institute of Gastroenterology 1Medical Gastroenterology, and 2Surgical Gastroenterology, Hyderabad, India

AIMS: Patients with cirrhosis carry higher risk for invasive procedures. Risks associated with surgical interventions are well studied; however there is little literature available for ERCP in cirrhosis. Hence, we analysed data of patients with liver cirrhosis who underwent ERCP. METHODS: We retrospectively evaluated all patients with cirrhosis who underwent ERCP from March 2014 to May 2016 at Asian Institute Of Gastroenterology, Hyderabad, India. Patient’s demographic characteristics, etiology of cirrhosis, CTP scores, ERCP indications, procedure details, complications and mortality were collected.

RESULTS: A total of 134 patients underwent ERCP (78 % men, age 53.3 12.35 years) were included in the analysis. Indications for ERCP were as follows: Choledocholithiasis (n = 38), BBS (n = 29), CBD leak (n = 2), malignant biliary obstruction (n = 39), PD leak (n = 7) and chronic pancreatitis (n = 19). A total of 29, 69 and 36 patients had CTP class A, B and C respectively. 40 patients (29.9%) had cholangitis at presentation. Pancreatic and biliary sphincterotomy was done in 26 (19.4%) and 73 (54.5%) patients. 30 patients underwent PD stent placement (4 - prophylactic stenting), while 28 patients underwent biliary SEMS placement and 65 patients underwent biliary plastic stent placement (15 multiple biliary stent). 17 patients (12.68%) had procedure related complications, which were more in higher CTP score, coagulopathy and presence of ascites. 2 patients had Post-ERCP pancreatitis (1 - mild, 1 - moderate); 4 patients had bleeding (1 mild, 1 moderate, 2 - severe); 10 patients had cholangitis (2 mild, 3 - moderate, 5 - severe) and one patient had atrial

AIMS: Outcome measures of Endoscopic Gall bladder stenting (EGS) using ERCP in high risk patient of acute cholecystitis who are unfit for surgery. METHODS: Acute cholecystitis was diagnosed by typical clinical features supported by ultrasonography and computed tomography. ERCP was done in all patients with 180 series of Olympus under deep sedation (propofol and midazolam). All patients underwent EGS, with a 7Fr double pig-tail stent being inserted into the gallbladder. After selective bile duct cannulation, a 0.025- or 0.035-inch guidewire (angle-tip, VisiGlide; Olympus Medical Systems, Tokyo, Japan) was advanced into the cystic duct under fluoroscopy guidance and subsequently into the gallbladder. Finally, a 5F to 7F single-pigtail naso-gallbladder catheter or a 7F double-pigtail stent was inserted into the gallbladder for ENGBD or EGS respectively. In this study, the primary endpoint was the technical success rate. The secondary endpoints were the clinical success rates and procedure-related adverse events. Technical success was defined as placement of a double-pigtail stent in the gallbladder or into cystic duct.

RESULTS: A total of 12 high risk surgical patients underwent EGS with technical success rate 85%. The procedure failed in 2/ 14 () due to inability to cannulate cystic duct. Clinical success was achieved in all except one patient who had only partial resolution with persistent symptoms. CONCLUSIONS: EGS can be effective for patients with acute cholecystitis who are poor surgical candidates as a temporary measure before cholecystectomy and the stent can be left for many months to several years. Conflict of Interest: None declared.


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P280: THE EXPERIENCE OF SIMULTANEOUS AND SEQUENTIAL DOUBLE STENTING IN COMBINED MALIGNANT BILIARY AND DUODENAL OBSTRUCTIONS

AIMS: To assess cholangiography changes and to evaluate efficacy and safety of endoscopic treatment of symptomatic PCC.

Ayesha Aslam Rai, Syed Mudassir Laeeq, Nasir Hassan Luck

treated between 1994–2016 were reviewed and analyzed. All patients with CBD calculi underwent endoscopic sphincterotomy (ES) and stone extraction, stricture dilatation and mechanical lithotripsy, when needed. Till 2005, plastic stent was placed prior to portosystemic shunt surgery (PSS) for biliary strictures, whereas in case of unsuccessful surgery, periodic stent exchange was done either every 3–4 monthly on regular basis or ‘on-demand’ basis. After 2005, strictures were managed according to standard BBS protocol, using Controlled Radial Expansion (CRE) balloon dilatations, and placement of multiple plastic stents (stent bundles, 2–8 plastic stents) with regular stent exchanges. This was continued till normal blood tests, clearance of CBD and complete/near-complete stricture resolution.

Sindh Institute of Urology and Transplantation, Hepatogastroenterology, Karachi, Pakistan

AIMS: The advances in less invasive methods for the relief of unresectable malignant enterobiliary obstruction is increasingly being considered the preeminent way of relieving jaundice. Endoscopic metallic stenting is a safe and effective procedure for palliative management, but it can be technically challenging when malignant biliary and duodenal obstructions coexist. The aim of our study was to share our experience regarding evaluation of clinical success rate, complications, resolution of symptoms and survival of endoscopic double stent placement for the management of combined malignant entero-biliary obstruction. METHODS: A prospective study was conducted on patients referred for management to the tertiary care, hepatogastroenterology unit, Sindh institute of urology and transplantation (SIUT), from April 2013 to April 2015.

RESULTS: Twelve consecutive patients predominantly females 8 (66.7%) were enrolled. Biliary stenting was followed by duodenal stenting in all cases, however in five patients endoscopic biliary stenting failed so rendezevous procedure was done. A technical success rate of 100 % was achieved, with procedure related early complication i.e. perforation occurred in 1 (8.3%) case. The quality of life significantly improved as assessed by resolution in jaundice (TB, P -value 0.002) and resumption of oral intake from GOOSS =0 pre-procedure to GOOSS=3 in 9 (75%) patients post-procedure. The overall median survival following double stenting was 66.25 days (range 14–149 days).

METHODS: 36 consecutive patients with symptomatic PCC

RESULTS: A total 236 sessions of ERCP were performed for 36 patients (range 2–25, mean 7.2) with a median of 3.2 stents placed in each session (range 1–8) over treatment duration of 17 months (range 1–188 months). 29 patients had jaundice prior to ERCP, with mean serum total bilirubin levels of 10.5 (range 2.2–43) mg/dL. 34 had biliary stenosis and, 9 had intrahepatic stenosis. Most common site of stenosis was mid CBD. 19 patients had CBD and/or CHD stone whereas 9 had intrahepatic stones, with a mean size of 11.5 (range 5–19) mm. There were 9 episodes of significant hemobilia (>200 mL), in 8 patients, that occurs mainly during CRE dilatation and/or stent removal. Biliary obstruction resolved in19 patients (now stent free), 6 were expired, 5 continue to be on stent exchange, and 6 were lost to follow-up. CONCLUSIONS: Symptomatic PCC can be managed successfully with endoscopic therapy as first line options with minimal risk of significant hemobilia. Conflict of Interest: None declared.

CONCLUSIONS: Combined endoscopic entero-biliary SEMS placement is a safe, less-invasive and technically feasible palliative treatment for patients with both duodenal and biliary obstruction, carrying high success rate, less morbidity, shorter hospital stay and significantly improved quality of life. Conflict of Interest: None declared.

P281: ENDOSCOPIC MANAGEMENT OF BILIARY OBSTRUCTION IN PATIENTS WITH SYMPTOMATIC PORTAL CAVERNOMA CHOLANGIOPATHY (PCC): EXPERIENCE OVER 20 YEARS (1994–2016) Kamlesh Kumar, Vivek Anand Saraswat, Nakul Morakhia, Tarun Kumar, Piyush Ranjhan, Gaurav Pandey, Samir Mohindra SGPGIMS, Gastroenterology, Lucknow, India

P282: BACTERIOLOGICAL PROFILE IN PATIENTS WITH ACUTE ASCENDING CHOLANGITIS Nitin Jagtap1, Pintu Bhakhar1, K. Anuradha2, Manu Tandon1, Sundeep Lakhtakia1, Rajesh Gupta1, Mohan Ramchandani1, D. Nageshwar Reddy1 Asian Institute of Gastroenterology 1Medical Gastroenterology, and 2Dept of Microbiology, Hyderabad, India

AIMS: Emerging resistance antibiotics is major problem in clinical practice. We aimed to study bacteriological profile in patients with acute cholangitis who underwent ERCP. METHODS: A retrospective study conducted between January 2016 to August 2016 at Asian Institute Of Gastroenterology, Hyderabad, India. Bile samples were collected in patients with


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 acute cholangitis during ERCP. Standard hospital protocol was followed for bacterial culture and sensitivity.

RESULTS: 189 patients with acute cholangitis were recruited. 134 Patients were (70.9%) male and the mean age was 48.5 years old. The bile was positive for bacterial growth in 165 patients (87.3%); while blood culture was positive in 49 patients (25.9%). The most commonly isolated organism was E. coli (n = 50, 30.3%) followed by Klebsiella pneumoniae (n = 34, 20.6%), Pseudomonas sp. (n = 26, 15.7%), and Enterobacter (n = 19, 11.4%). Mixed growth was isolated in 28 (17%). Aminoglycosides (88%), carbapenems (84%), cephalosporins (92% - 3rd or 4th generations) gives better sensitivity than fluoroquinolones (26%), piperacillin-tazobactam (46 %). Carbapenem resistant Enterobacteriaceae was isolated in < 2% patients.


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mean time to elective cholecystectomy after ERCP was similar with both groups; 6.5 6.3 days and 5.8 6.6 days for the patients with or without biliary stent insertion, respectively. However, the length of hospital days for patients after cholecystectomy was longer in the patients with biliary stent insertion; 5.5 4.1 days and 4.3 2.6 days, respectively (P = 0.037). Stents were migrated to intestine in 75 patients within 2 weeks and removed with endoscopy at average 15 days in 20 patients.

CONCLUSIONS: Prophylactic biliary stent insertion during ERCP before cholecystectomy has no impact on biliary events. Biliary stenting may be helpful in selected patients with risk factors of biliary complications. Conflict of Interest: None declared.

CONCLUSIONS: Initial empirical antibiotics therapy for patients with acute cholangitis should include 3rd or 4th generation cephalosporins or carbapenems along with ERCP and biliary drainage. Conflict of Interest: None declared.

ERCP: BILIARY: ENDOSCOPY: ERCP STONES P283: PROPHYLACTIC BILIARY STENT TO THE COMMON BILE DUCT DURING ERCP BEFORE CHOLECYSTECTOMY 1

1

2

Seon Mee Park , Joung-Ho Han , Jae-Woon Choi , Sei Jin Youn1 Chungbuk National University Hospital 1Internal Medicine, and 2General Surgery, Cheongju, Korea

AIMS: Patients having stones in the gallbladder and in the common bile duct usually undergo ERCP followed by elective cholecystectomy. While waiting for cholecystectomy, recurrent biliary events or complications of ERCP can occur. This study aimed to investigate whether biliary stent insertion before cholecystectomy influences the rate of complications and hospital courses. METHODS: Patients having stones in both common bile duct and gallbladder underwent ERCP before cholecystectomy. After complete stone removal during ERCP, biliary stent (7Fr, 5 cm, single pigtail) with flap removal was inserted in the common bile duct. The rates of biliary events while waiting for elective cholecystectomy and hospital courses were analyzed.

RESULTS: Ninety-six patients with stent insertion (M:F, 52:44; mean age, 61.3 17.5 years) and 57 patients without stent insertion (M:F, 27:30; mean age, 60.6 16.8 years) were enrolled in this study. The percentages of acute cholangitis and acute pancreatitis at admission were not different between groups. ERCP related events were also not different. Stone impaction in the CBD did not occur in anyone before cholecystectomy. Repeat ERCP after cholecystectomy was done in two and one patients with or without biliary stents, respectively. The

P284: COMPLICATED CHOLEDOCHOLITHIASIS DIAGNOSTIC AND TREATMENT Mikhail Korolev, Leonid Fedotov, Ruben Avanesyan, Boris Fedotov Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russia

AIMS: To show effectiveness of combined transcutaneous and endoscopic manipulations in complicated choledocholithiasis. METHODS: Department of common surgery with the course of endoscopy treating mentioned patients in last 25 years. Methods of combined interventions under ultrasonic, x-ray and endoscopic control were used for treatment patients with complicated choledocholithiasis since 2006. Now we have an experience of 156 treated patients with choledocholithiasis, wich we evaluate as “complicated”. Patients in this group are: 1 - very high level of bilirubin in blood (500 mmol/l and more) - 16 patients. 2 - patients with choledocholithiasis in which you can’t remove stones because of the severe comorbidities - 23 patients. 3 - unremovable stones with Dormia basket or lithotripter 39 patients. 4 - technical difficulties during cannulation of papilla Vateri (diverticula, malformations) - 73 patients. 5 - altered anatomy of upper GI-tract (surgical interventions), when you can’t get the scope to the papilla. All patients of these groups were treated using combined miniinvasive interventions, which included antegrade and retrograde methods, made under ultrasonic, x-ray and endoscopic control in several stages or in the same time.

RESULTS: Percutaneous biliary drainage before removing stones - 78 patients. Percutaneous guidewire into the duodenum in cases with diverticula and malformations - for safe sphincterotomy - 73 patients. Method of antegrade placed manipulation catheter in gastric stump or diverting intestinal loop - 5 patients with altered anatomy, to get scope to papilla. After performing these manipulations we had complications in


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11 patients (7.4%), mortality was 1.28% (2 patients), all other patients were treated successfully.

CONCLUSIONS: 1 - combined miniinvasive interventions in almost all cases of choledocholithiasis (also complicated) allow to remove stones from bile ducts. 2 -percutaneous biliary drainage is necessary after combined stone removing. Conflict of Interest: None declared.

P286: MULTICENTER RANDOMIZED CONTROLLED STUDY OF ENDOSCOPIC BILIARY STONE EXTRACTION USING EITHER A BASKET OR A BALLOON CATHETER: THE BASKETBALL STUDY Ichiro Yasuda1, Noritaka Ozawa1, Shinpei Doi1, Takuji Iwashita2, Masahito Shimizu2, Tsuyoshi Mukai3, Masanori Nakashima3, Tesshin Ban4, Issei Kojima4, Koichiro Matsuda5, Mitsuru Matsuda5, Yusuke Ishida6, Yoshinobu Okabe6, Nobuhiro Ando7, Keisuke Iwata7 1

P285V: ENDOSCOPIC MANAGEMENT OF IMPACTED BILE DUCT STONES THAT CANNOT BE TRAVERSED BY A WIRE Arvind Trindade1, Sumant Inamdar2, Douglas Pleskow3 1 Long Island Jewish Medical Center, Gastroenterology/ Endoscopy, New Hyde Park, 2Long Island Jewish Medical Center, Medicine, Gastroenterology, New Hyde Park, and 3 Harvard Medical School, Beth Israel Deaconess Medical Center, Gastroenterology, Boston, USA

AIMS: Successful removal of impacted stones can be technically difficult when a wire cannot traverse the obstruction. This scenario, albeit rare, can happen especially with stones impacted in the intrahepatic bile ducts and ampulla. There is limited literature on the ideal endoscopic technique to remove these stones. METHODS: We report a case series of three patients; two impacted ampullary stones and one impacted intrahepatic duct stone successfully removed by endoscopic retrograde cholangiography. In all three cases a 0.025-inch wire could not be advanced around the fixed obstruction.

RESULTS: For the impacted ampullary stones, the stones were successfully removed using free hand needle knife sphincterotomy over the stone. This allowed for the stones to be dislodged from the ampulla. Biliary access was then possible by traditional wire access to provide further therapy. For the impacted intrahepatic stone, a wire could be advanced from the ampulla to the distal side of the stone. However, a wire could not traverse the stone to the proximal side of the stone; even with cholangiosocpy directed wire placement. Therefore, digital cholangioscopy was used for electrohydraulic lithotripsy to fragment the stone. Once the stone was fragmented into pieces, a wire was able to traverse the previous area of impaction and allow for balloon catheter removal. Complete stone removal was achieved in all three cases with procedural and clinical success. No adverse events occurred.

Teikyo University Mizonokuchi Hospital, Kawasaki, 2Gifu University Hospital, Gifu, 3Gifu Municipal Hospital, Gifu, 4 Nagoya Daini Red Cross Hospital, Nagoya, 5Toyama Prefectural Central Hospital, Toyama, 6Kurume University, Kurume, Japan and 7Gifu Prefectural Medical Center, Gifu, Japan

AIMS: In Japan and Europe, a retrieval basket is generally used for endoscopic extraction of bile duct stones, while in the US, a retrieval balloon is mainly used. However, the efficacies of these two devices have not been previously compared. Therefore, the present multicenter, prospective, randomized study was performed to compare the efficacies of these two devices for endoscopic biliary stone extraction. METHODS: This study was designed as a non-inferiority study in comparing a basket removal with a balloon removal. Six Japanese institutions participated in this study, which included 184 patients with bile duct stones ≤11 mm in diameter with no limitation in the number of stones. The stones were identified and measured during ERCP, after which the patients were randomly assigned to undergo endoscopic stone extraction using either a basket catheter or a balloon catheter. The primary end point was the rate of complete removals of stones within 10 minutes, and the secondary end point was the rate of procedure-related complications.

RESULTS: There were 91 patients in the basket group and 93 in the balloon group. The rate of successful stone extraction within 10 minutes was 81.3% (74/91) in the basket group and 83.9% (78/93) in the balloon group (P = 0.7000). The complication rate was 6.6% in the basket group and 11.8% in the balloon group (P = 0.3092). Complications included bleeding, pancreatitis, and cholangitis. CONCLUSIONS: Basket and balloon catheters showed similar efficacies for endoscopic biliary stone extraction when stone size is 11 mm or smaller. Conflict of Interest: None declared.

CONCLUSIONS: Impacted bile duct stones that cannot be traversed with a bile duct wire can be challenging to remove. We show in this case series that they can be safely removed endoscopically. Free hand needle knife sphincterotomy over the stone can be used for stones impacted at the ampulla. Cholangiosocpy with electrohydraulic lithotripsy can be used for stones impacted in the intrahepatic bile ducts. Conflict of Interest: None declared.



P287: PREDICTIVE FACTORS OF UNSUCCESSFUL CLEARANCE OF COMMON BILE DUCT AFTER ENDOSCOPIC TREATMENT OF BILE DUCT STONES riam Sabbah1, Asma Ouakaa1,2, Hela Dalila Gargouri1,2, Me Elloumi1,2, Nawel Bellil1,2, Norsaf Bibani1,2, Dorra Trad1,2, Jamel Kharrat1,2 1

Habib Thameur Hospital, Gastroenterology, and 2University of Tunis El Manar, Faculty of medicine of Tunis, Tunis, Tunisia

AIMS: Endoscopic management of common bile duct (CBD) stones is widely accepted. However, sometimes, clearance of CBD is not obtained. The aim of this study was to identify predictors of unsuccessful clearance of CBD.

METHODS: A retrospective study of ERCP indicated for CBD stones (July 2014 - September 2015) was performed. First line endoscopic treatment consisted in endoscopic sphincterotomy (SE), followed by stones extraction by a Dormia basket or balloon. Mechanical lithotripsy was sometimes necessary. In some cases, a macrodilatation of the papilla was performed. Failure of CBD clearance was defined by persistence of stones after endoscopic procedure.

RESULTS: 310 ERCP were performed. 238 (76.7%) were done


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AIMS: With the advancement of an aging society, acute cholangitis due to common bile duct stones in the elderly is increasing. For the common bile duct stone patients, we have done endoscopic lithotripsy in principle. However, we have performed only endoscopic biliary stenting for the elderly high risk common bile duct stone patients that endoscopic treatment may become invasive for the long term cure. This study revealed the usefulness of endoscopic biliary stenting for the elderly high risk common bile duct stone patients. METHODS: We have compared with 18 cases (group A) that we have performed only endoscopic biliary stenting and 64 cases (group B) that we have done endoscopic lithotripsy over 75 years old. Examination items were patient background, treatment time, hospitalization and complications.

RESULTS: In group A, multiple stones (≧4) were found significantly more than group B. And in group A, treatment time and hospitalization were shorter than group B. Recurrent cholangitis due to stent occlusion and migration was significantly more than group B in group A. It was observed in 8 cases of group A, the average time to the recurrence was 252 days. Recurrent cholangitis was light by stent exchange in the short-term hospitalization. CONCLUSIONS: The endoscopic biliary stenting for the elderly high risk common bile duct stone patients is useful and safety. Conflict of Interest: None declared.

for CBD stone. Bile duct access was possible in 201 cases (84.4%). Cholangiography showed a single stone in 81 cases, multiple stones (over 3) in 54 cases and large stone (>15 mm) in 16 cases. Stenosis of the CBD was found in 10 cases (4.2%). A periampullary diverticulum was noted in 30 cases (12.6%). An SE was performed in 74.4% of cases (n = 177), an infundibulotomy in 11 0.8% (n = 28), and a macrodilatation of the papilla in 4.6% of cases (n = 11). Mechanical lithotripsy was performed in 3.8% (n = 9). Stone extraction was possible in 74% of cases (n = 176) reaching 88% after repeated endoscopy. In univariate analysis, failure of CBD access (P < 0.005), large stone (P = 0.007), multiple stones (P = 0.042), periampullary diverticulum (P = 0.035), and a bile duct stenosis (P = 0.013) were predictors of failure of extraction. In multivariate analysis; large stone, multiple stones and stenosis were independent predictors of unsuccessful clearance of CBD.

AIMS: To compare CBD clearance rate by either open surgery, laparoscopy, or endoscopy, in a well-equipped tertiary center.

CONCLUSIONS: Unsuccessful clearance of CBD after first

METHODS: 250 cases of choledocholithiasis were included

endoscopic procedure was noted in 26% of cases. Large and/or multiples stones, CBD stenosis were independent predictors of unsuccessful clearance of CBD. Conflict of Interest: None declared.

from general surgery department, Sohag university hospital and managed randomly by conventional surgery, endoscopic approaches, and laparoscopic techniques.

P288: THE USEFULNESS OF ENDOSCOPIC BILIARY STENTING FOR THE ELDERLY HIGH RISK COMMON BILE DUCT STONE PATIENTS Ryota Tokunaga1,2 1 2

Showa University Ko-To Toyosu Hospital, Chuo-Ku, and Showa University Ko-To Toyosu Hospital, Ko-to-Ku, Japan

P289: COMMON BILE DUCT CLEARANCE OF STONES BY OPEN SURGERY, LAPAROSCOPIC SURGERY, AND ENDOSCOPIC APPROACHES (COMPARATIVE STUDY) Alaa Redwan, Mohammed Ahmad Omar Sohag University, GIT Surgery and Laparo-Endoscopy, Sohag, Egypt

RESULTS: Mean age was 40 years, with slight female predominance (1.6: 1), mostly presented with calcular obstruction (54.3%). Patients were categorized randomly into: Group I included 100 patients (40%) treated by choledocholithotomy, the time was about 90 min. with success rate reached 100%, CBD clearance in 95% of cases, hospital stay was around 8 days, no mortality, morbidity rate of 15%, and return to work after 2 weeks. Group II included 100 patients (40%) treated by endoscopic sphincterotomy and basket extraction in 45%, balloon in 25%, combined maneuver in 15%, mechanical lithotripsy in 13%, and


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failure in two cases (2%), time was about 30 min. with success rate 98% and CBD clearance of 100%, no mortality, morbidity of 9%, hospital stay was about 1 day, and return to work after 3 days. Group III included 50 cases (20%) treated by laparoscopic CBD exploration either trans-cystic in 5 cases, or transcholedochotomy in 45. Choledochoscopy was done in almost all cases (45 cases) to detect or extract the stones and assure clearance, conversion to open in 1 case. time needed for was about 123 min, with clearance 96%, no mortality, and morbidity rate about 10%. Hospital stay was 3.2 days, and return to the work after 7 days.

Abdominal pain, jaundice and fever were present in 8, 9 and 6 patients respectively. The mean values of bilirubin, AST, ALT and SAP were 10.6 mg%, 174 IU/mL, 156 IU/mL and 492 IU/mL respectively. Six of the 13 (46%) patients required both BS and ML for CBD clearance, whereas only ML was required in 2 patients.

CONCLUSIONS: WG-CBD occurs in a small proportion of

CONCLUSIONS: Both ERCP/LC and LCBDE were highly effec-

patients with CBD calculi. It is characterized by higher values of bilirubin and frequent need for ML and BS. USG is not useful in detecting this entity. MRCP is useful in the pre-procedural diagnosis of the wine glass CBD. Conflict of Interest: None declared.

tive, and equivalent in overall cost and patient acceptance. However, hospitalization was shorter for LCBDE with elimination of ERCP, anesthetic complications, and the need for another procedure. It is feasible, cost-effective, and ultimately should be available for most patients in each specialized center. Conflict of Interest: None declared.

P291: EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY FOR DIFFICULT BILE DUCT STONES, A NINE YEAR SINGLE CENTER EXPERIENCE Nasir Hassan Luck1, Muhammad Manzoor U. Haque2, Abbas Ali Tasneem2

P290: FREQUENT NEED FOR MECHANICAL LITHOTRIPSY AND BALLOON SPHINCTEROPLASTY IN PATIENTS WITH NON-DILATED DISTAL SEGMENT OF CBD: THE WINE GLASS CBD (WG-CBD)

1

Amarender Puri1, Sanjeev Sachdev2, Sunil Puri3

AIMS: Extracorporeal shock wave lithotripsy (ESWL) for common bile duct (CBD) stone has been used before but experience is limited. We herein report our experience with ESWL in the management of difficult biliary stones which could not be retrieved on initial ERCP.

1 GB Pant Institute of Postgraduate Medical Education and Research, Gastroenterology, 2GB Pant Institute of Postgraduate Medical Education and Research, Gastroenterology, and 3GB Pant Institute of Postgraduate Medical Education and Research, Radiology, New Delhi, India

AIMS: Endoscopic sphincterotomy (ES) is procedure of choice for removal of CBD calculi. Failure of ES to clear CBD calculi may be related to several factors. WG-CBD is a poorly reported entity which is likely to result in failed CBD clearance. USG is a poor diagnostic modality for the diagnosis of WG-CBD. We report our experience of this entity in patients who were detected on either MRCP or during ERCP at our centre over the past 2 years. METHODS: Retrospective analysis of 13 patients diagnosed to have WG-CBD with intra-ductal calculi during ERCP or on MRCP examination over the past 2 years was done. Inclusion criteria were differential dilatation of the upper segment of CBD/CHD with respect to a non-dilated segment CBD in the absence of any prior surgery or biliopancreatic malignancy. Need for Mechanical lithotripsy (ML) and Balloon sphincteroplasty (BS) was recorded in these patients. Biochemical profile of the patients was recorded. Endpoint was the successful clearance of the calculi with ES, ML or BS.

RESULTS: Of the1900 ERC procedures performed 13 (0.7%) were diagnosed to have WG-CBD with intra-ductal calculi. The mean age of these 13 patients (9 females) was 45 years. USG failed to detect the distal non-dilated segment in all 13 pts.

Showa University Koto-Toyosu Hospital, HepatoGastroenterology, and 2Sindh Institute of Urology and Transplantation, Hepatogastroenterology, Karachi, Pakistan

METHODS: This study was conducted from January 2007 to September 2016 in department of Hepatogastroenterology, SIUT. All patients with difficult to retrieve CBD stones who underwent ESWL were enrolled. Stones were targeted fluoroscopically, following injection of contrast via nasobiliary drain (NBD). Outcome was assessed by CBD clearance. Both early and late complications were noted.

RESULTS: Sixty one patients were included, mean age 48.1 14.3; predominantly females 32 (52.5%). Patients with large stones >15 mm were seen in 46 (74.5%), CBD stricture in 18 (29.5%) and incarcerated stone in 8 (13.1%) patients. Jaundice was present in 42 (68.9%) patients, cholangitis 21 (34.4%), fever 26 (42.6%) and right upper abdominal pain 8 (13.1%). A total of 123 ESWL sessions were performed in 61 patients, with 2.02 1.08 sessions of lithotripsy and 4176 1526 shockwaves per session. In 48 (78.6%) patients, the fragments were extracted endoscopically after ESWL, while spontaneous passage was observed in 08 (13.1%) patients. Total CBD clearance was achieved in 48 (78.6%) patients, partial clearance in 3 (4.9%) and no response in 10 (16.5%). Most frequent side effects were abdominal pain followed by macroscopic and microscopic hematuria 9 (14.8%), fever 8 (13.1%), cholangitis 7 (11.5%) and hemobillia 3 (4.9%). NBD was displaced or removed by the patient in 6 (9.8%) cases. ESWL session could not be completed or temporarily held in 10 (16.4%) patients due to development of


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 complications. Total hospital stay was 12.1 7.22 days (range 1–42).

CONCLUSIONS: ESWL is noninvasive safe and effective therapeutic alternative to surgical exploration for difficult biliary stones. Conflict of Interest: None declared.


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ERCP: BILIARY: ENDOSCOPY: ERCP STRICTURES P293: EFFICACY, SAFETY AND REMOVABILITY OF COVERED, MULTI-HOLE METAL STENT IN HILAR BILIARY STRICTURE OF SWINE MODEL: A FEASIBILITY DATA Jin-Seok Park, Yong Woon Shin, Don Haeng Lee, Seok Jeong

P292: ERCP FINDINGS AND RESULTS IN CHOLEDOCHOLITHIASIS: AN EXPERIENCE AT A HIGH VOLUME CENTRE Vinod Dixit, Sunit Shukla, Sudhir Singh, Gaurav Garg, Shivam Sachan Institute of Medical Sciences, Banaras Hindu University, Gastroenterology, Varanasi, India

AIMS: ERCP is the preferred modality for treating choledocholithiasis as it can curb the need for major surgery in most cases. To study the demographic profile of patients presenting with choledocholithiasis and to study the findings and results of various therapeutic modalities. METHODS: We studied 433 successive patients of choledocholithiasis presenting to our centre for ERCP over a period of 1 year in terms of their demographic profile, postcholecystectomy status, number, size and location of stones and therapeutic modalities and their results.

RESULTS: Out of 433 patients of choledocholithiasis who reported for ERCP, 120 (27.7%) were males and 313 (72.3%) were females. Most common age group in both the sexes was 40– 60 years (45%). 21 (4.8%) patients were of post-cholecystectomy status. 32 (7.3%) patients had associated periampullary diverticulum. CBD stricture was associated in 40 (9.2%) patients. Periampullary growth was associated in 18 (4.1%) patients. 221 (51%) patients had stone 2 organs (n = 8)]. Common clinical presentations were hepatomegaly, jaundice and weight loss. Mean time from symptom onset to presentation was 200 days (range 7–710). Diagnosis was made by presence of caseating granuloma in biopsy of liver (n = 5), bile duct (n = 1), colonic ulcer (n = 4), peritoneal nodule (n = 1) and liver nodule (n = 1). In three patients, diagnosis was made during endoscopic ultrasound fine needle aspiration cytology of celiac node (n = 1), hilar node (n = 1) and pancreatic lesion (n = 1). One patients bile culture was positive for tuberculosis and another two patients had

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 smear positive tuberculosis. Two patients bile samples tested positive for Gene Xpert MTB-RIF assay. Fifteen patients had biliary strictures. Of these, ten had hilar strictures and five had strictures at the common bile duct (CBD). Three patients had multisegmental intrahepatic duct (IHD) strictures. All patients were treated with anti-tuberculous drugs for twelve to eighteen months. Patients with jaundice and biliary strictures also underwent biliary stenting for decompression. Three patients had metallic stenting during initial presentation due to misdiagnosis as malignancy. Of the other ten patients who had biliary stenting, one patient required long-term biliary stenting after completion of treatment. Another three no longer required stenting after 12 months of treatment. Six others are still undergoing treatment.

CONCLUSIONS: There should be a high index of suspicion of HTB in tuberculosis endemic areas as delay in diagnosis can result in significant mortality and morbidity. Conflict of Interest: None declared.

P296V: POSTCHOLECYSTECTOMY, COMPLEX BILE DUCT INJURY, VASCULAR INJURY (RHA ANEURYSM), EHBO, CHOLANGITIS, INFECTED HEMO-BILOMA: COMBINATION OF ALL COMPLICATIONS IN A SINGLE PATIENT, MANAGED BY MULTIDISCIPLINARY APPROACH Hemanta Nayak, Vivek Saraswat, Samir Mohindra, Gaurav Pande Sanjay Gandhi Postgraduate Institute, Department of Gastroenterology and Hepatology, Lucknow, India

AIMS: We report a patient with bile duct injury (BDI) following open cholecystectomy, who developed biloma, RHA aneurysm causing biliary obstruction, and also had a biliary stricture at the site of BDI. METHODS: A 55 year female underwent laparoscopic converted to open cholecystectomy for symptomatic gall bladder stone. She developed severe abdomen pain associated with high grade fever, jaundice and pruritus 20 days following surgery. On evaluation she had anemia with hemoglobin of 6.4 g%, total leukocyte count of 22,300 cells/mm3. There was conjugated hyperbilirubinemia with a total bilirubin of 9 mg/dL and elevated alkaline phosphatase, 5 times above the normal range. CT angiography showed a large pseudoaneurysm of right hepatic artery from cholecystic branch, with bilobar IHBRD and 20 X 13 hematoma/bilioma at lesser sac and another collection in lesser omentum. DSA and angio-embolization was done for pseudoaneurysm. Oesophagogastroduodenoscopy showed a large extrinsic compression of stomach. Endoscopic gastrostomy and transmural drainage of biloma was done using NAGI stent. Endoscopic retrograde cholangiogram (ERC): Leak was seen at hilum and 3 systems were separated. Wire could only be placed to RASD and LHD; plastic stents were placed in




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both these ducts. Following the procedure jaundice and fever had improved.

There were no severe complications associated with endoscopic intervention.

RESULTS: USG abdomen and CT abdomen repeated after 8 week, confirmed resolution of collection and adequate biliary decompression. NAGI stent was removed. She underwent 4 sessions of stent exchange programme. Stricture opened up at hilum, now she is stent free for past 6 month.

CONCLUSIONS: Endoscopic treatment for biliary strictures

CONCLUSIONS: Here we described an unique patient of post-

P298: ACCUMULATION OF DOUBLE STENTING FOR MALIGNANT GASTRODUODENAL AND BILIARY OBSTRUCTION

CCX, complex BDI with vascular injury and biloma with extrahepatic biliary obstruction, which was successfully managed by multidisciplinary approach. Early endoscopic management using a combined (transgastric and transpapillary) approach, should be considered as an option, in the management of postcholecystectomy large bilomas with bile leak and biliary strictures; to avoid the development of refractory biliary strictures. Conflict of Interest: None declared.

P297: ENDOSCOPIC TREATMENT OF BILIARY STRICTURES AFTER ADULT LIVING DONOR LIVER TRANSPLANTATION WITH DUCT-TO-DUCT RECONSTRUCTIONΔ Tatsuya Sato1, Hirofumi Kogure1, Hiroyuki Isayama1, Naminatsu Takahara1, Suguru Mizuno1, Saburo Matsubara1, Yousuke Nakai1, Minoru Tada1, Nobuhisa Akamatsu2, Junichi Kaneko2, Norihiro Kokudo2, Kazuhiko Koike1 University of Toky, 1Department of Gastroenterology, and 2 Artificial Organ and Transplantation Division, Department of Surgery, Tokyo, Japan

AIMS: Biliary strictures after living donor liver transplantation (LDLT) with duct-to-duct (D-D) reconstruction is a serious postoperative complication with high morbidity and mortality. The aim of this study is to evaluate the effectiveness of endoscopic treatment for biliary strictures after LDLT. METHODS: Between 2000 and 2016, 480 adult LDLTs were performed in our institution. 96 patients were referred to our department for endoscopic treatment. First, they were treated by balloon dilatation of strictures followed by a nasobiliary catheter placement across the stricture. If stricture resolution was not achieved, then plastic stents were inserted across the strictures, which were placed completely into the bile duct (inside stents).

RESULTS: The type of graft was the right liver in 56, left liver in 34, and right lateral segment in 6 patients. Endoscopic approach was successful in 84 of 96 patients (88%). The rate of stricture resolution by balloon dilatation was 69%(36 of 52). The cumulative recurrence rate after successful balloon dilatation was 44% at 1 year and 60% at 5 years, respectively. 63 patients required plastic stent placement, and successful removal of plastic stents was achieved in 25 patients (40%) with median indwelling time of 1036 days. 34 patients (54%) underwent a scheduled stent exchange for every 4–12 months.

after LDLT with D-D reconstruction is safe and effective. Conflict of Interest: None declared.

Taito Fukushima, Jun Hamanaka, Yusuke Sano, Hiroshi Okazaki Yokohama Minami Kyosai Hospital, Gastroenterology, Yokohama, Japan

AIMS: Malignant gastroduodenal and biliary obstruction is a common complication in patients with gastroduodenal or pancreatobiliary malignancies. Self-expandable metal stents (SEMS) have been established as a palliation way in patients with such obstruction, however double stenting is technically difficult when combined gastroduodenal and biliary obstruction exist. METHODS: The aim of this study was to evaluate the effectiveness and technical feasibility of double stenting. Medical records of 15 patients that underwent double stenting from April 2010 to March 2016, 15 were analyzed retrospectively.

RESULTS: The stenting procedure was successful in 15 patients (100%). The duodenal strictures were proximal to the papilla in 7 patients, adjacent to the papilla in 5 patients and distal to the papilla in 3 patients. Average score according to the gastric outlet obstruction scoring system (GOOSS) improved from 1.1 to 2.5. Early complications were 2 mild pancreatitis. Late complications were 6 cholangitis, 2 duodenal stent overgrowth and 2 gastrointestinal bleeding. The overall median survival after double stenting was 110 days.3 patients ware introduced chemotherapy after double stenting and each survival time was 447, 203, 149 days. CONCLUSIONS: Double stenting is safe and effective for palliation in malignant gastroduodenal and biliary obstruction. This technique has the potential to improve survival time by combination with chemotherapy. Conflict of Interest: None declared.

P299: NON SURGICAL MANAGEMENT OF HEPATICOJEJUNOSTOMY ANASTOMOTIC STRICTURES WITH INTRADUCTAL STONES: REPORT OF TWO CASES Raiza Geires Bondoc, Evan Ong Metropolitan Medical Center, Manila, Philippines


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AIMS: Laparoscopic cholecystectomy has 0.4–0.6% incidence rate of major bile duct injuries compared to open approach. Biliary-enteric bypass surgery is the definitive approach but complications include anastomotic strictures and intrahepatic lithiasis. Surgical revision is the best option but percutaneous transhepatic biliary drainage (PTBD) followed by dilation of strictures, may be a useful alternative. METHODS: Two patients underwent Roux-en-Y Hepaticojejunostomy for repair of laparoscopic cholecystectomy-related bile duct injury. Later on, both developed jaundice secondary to anastomotic stenosis resulting in intrahepatic duct stones. Both underwent PTBD through the left duct and the tracts serially dilated to Fr18. Despite regular flushing and partial stone extraction, the guidewire failed to bypass the anastomosis. Eventually, faint egress of dye into the jejunum was noted but guidewires still failed to enter the bowels. An Olympus bronchoscope was introduced into the tract and the tip positioned in the area of the supposed stenosis among stones and debris, and the guidewire maneuvered until it entered the jejunum. The stenosis was then dilated with CRE balloons from 8 to 15 mm. Eventually, the scope was able to enter the jejunum successfully.

RESULTS: In both cases, ductal clearance was achieved in the left duct and Fr16 catheters inserted into the jejunum to act as splint. The stones in the communicating right intrahepatic duct will be the next target of therapy. CONCLUSIONS: In cases where patients were not amenable for surgery, serial percutaneous and progressive catheter exchange coupled with balloon dilation were valuable alternative in managing anastomotic stenosis with intrahepatic stones. Conflict of Interest: None declared.

P300: ENDOSCOPIC MANAGEMENT OF POST CHOLECYSTECTOMY BENIGN BILIARY STRICTURE: SINGLE CENTRE EXPERIENCE Hemanta Nayak1, Vivek Saraswat1, Samir Mohindra1, Gaurav Pande1, Sachin Shetty2 1

Sanjay Gandhi Postgraduate Institute, Department of Gastroenterology and Hepatology, Lucknow, India and 2 Sanjay Gandhi Postgraduate Institute and Medical Sciences, Department of Gastroenterology and Hepatology, Lucknow, India

AIMS: Endoscopic management of post cholecystectomy benign biliary stricture (BBS) with multiple plastic stents is routinely practised. Our aim was to assess efficacy and outcome of multiple plastic stent placements in this patients. METHODS: A retrospective study was done in a tertiary referral center from January 2004 till August 2016. During each ERCP, increasing number of stents were placed and once the maximum number of stents were placed, they were left in situ for 3–6 months and all the stents were removed at the end of therapy. Early recoil was assessed after removing all stents and late recoil by cholangiogram through ENBD after 48 h.

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 RESULTS: Out of 75 patients, technical success was achieved in 72 patients (96%). Twenty five patients had type II stricture, 23 had type III, 13 had type I, 12 had type IV and only 2 had type V stricture. Due to inadequate drainage and unwillingness for repeat endothreapy, five patients underwent surgery. Six patients were lost to follow up and one patient died due to cardiac cause after initiation of endothreapy. Fifty two patients completed therapy and eight patients currently on stent exchange programme. Median age of patients was 39 years (range 23–86), median number of procedures per patient were 4.2 (range 2–7), median maximum number of stents placed per person were 4 (range 2–8), median duration of therapy was 13 months (range 6–26), median duration of follow up after completion of therapy was 37 months (range 3–94). Two patients had symptomatic recurrence of stricture 2 years which were managed by surgery and endothreapy. CONCLUSIONS: Endoscopic therapy is feasible in post cholecystectomy benign biliary stricture with technical success of 96%. Recurrence of stricture is rare and at the end of median follow up of about 3 years, bile duct was patent in 96% of patients who completed therapy. Conflict of Interest: None declared.

COLON AND RECTUM: ENDOSCOPY: COLORECTAL CANCER P301: PROPHYLACTIC CLIP CLOSURE OF MUCOSAL DEFECTS AFTER COLORECTAL ENDOSCOPIC SUBMUCOSAL DISSECTIONΔ Hideaki Harada, Satoshi Suehiro, Daisuke Murakami, Ryoutaou Nakahara, Takanori Shimizu, Yasushi Katsuyama, Kenji Hayasaka New Tokyo Hospital, Gastroenterology, Matsudo, Chiba, Japan

AIMS: Endoscopic submucosal dissection (ESD) is useful for en bloc resection to assess the accurate histopathologic diagnosis for superficial colorectal neoplasms. However, colorectal ESD is associated with a high rate of adverse events. Previous studies reported that prophylactic clip closure of colorectal mucosal defects after endoscopic resection reduced adverse events, such as delayed perforation, delayed bleeding, fever, and abdominal pain. The aim of this study was to investigate the effectiveness of clip closure of defects after colorectal ESD in comparison with patients without clip closure. METHODS: A total of 200 lesions in 186 consecutive patients underwent colorectal ESD at the New Tokyo Hospital between June 2010 and July 2016. Among them, 191 lesions in 177 patients were enrolled in this study. Prophylactic clip closure of mucosal defects was introduced and performed during the latest 2 years of this period. Clinical records were retrospectively reviewed and clinical outcomes were evaluated.


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 RESULTS: Adverse events occurred in 27 patients (14.9%), including 12 patients with delayed bleeding, 11 with fever, 2 with abdominal pain, 1 with delayed bleeding and fever, and 1 with fever and abdominal pain. Delayed perforation was not observed in any participant. Rate of adverse events in the clip closure group was significantly lower than that in the no clip closure group [8.3% (9/108) vs 21.7% (18/83); P = 0.012]. Multivariate analysis revealed that no clip closure [odds ratio (OR), 2.810; 95% confidence interval (CI), 1.070–7.350; P = 0.036], tumor size (≥40 mm) (OR, 3.560; 95% CI, 1.300– 9.790; P = 0.014), and submucosal fibrosis (OR, 3.860; 95% CI, 1.540–9.690; P = 0.004) were associated with adverse events after colorectal ESD. CONCLUSIONS: Prophylactic clip closure of mucosal defects decreased the rate of adverse events after colorectal ESD in patients with superficial colorectal neoplasms. Conflict of Interest: None declared.

P302: ENDOSCOPIC RADIOMETABOLIC TATOO TO DEFINE SENTINEL NODE IN RESIDUAL RECTAL CANCER: PRELIMINARY RESULTS OF OUR INITIAL EXPERIENCE Rosamaria Bozzi1, Pierluigi Angelini2, Fernando Bozzi3, Marco Bifulco4, Giovanni Borrelli4, Francesco Corcione2, Domenico Cattaneo1


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RESULTS: 9 CASES: In all SN was properly identified on SPECT-TC fusion imaging. 1 patient refused TC guided biopsy. 1 case biopsy was inadequate for diagnosis. 7 cases SN histology was negative. 1 case of negative histology there was a doubt FDG PET uptake of SN (discordant result in neoadjuvant CR). 8 patients underwent transanal endoscopic microsurgery. In the discordant case was prudentially chosen a robotic TME (N0 confirmed).

CONCLUSIONS: Our early preliminary cases showed that SPECT-TC following peritumoral submucosal endoscopic injection of 99 m-technetium-marked nanocolloid was able to identify rectal SN in 100% of cases The TC guided biopsy was adequate in 7/8 (87%) of cases SN histology was concordant with definitive histology (N0) in case of doubt PET. Conflict of Interest: None declared.

P303: INITIAL RESULTS OF A COMPARATIVE STUDY OF THE USE OF COVERED AND UNCOVERED STENTS NEW DESIGN: PROSPECTIVE, RANDOMIZED, SINGLECENTRE STUDY Victor Malyuga, Alexandr Vodoleev Eramishanzev Clinical Hospital, Moscow, Russia

1

Surgical Endoscopy - Az. Ospedaliera dei Colli, Dept. of Surgery, Napoli, Italy, 2General Surgery, Laparoscopi and Robotic Unit, Dept. of Surgery - Az. Ospedaliera dei Colli, Napoli, Italy, 3University of Sophia, School of Medicine, Sophia, Bulgaria and 4Nuclear and Radiometabolic Unit, Dept. of Radiology - Az. Ospedaliera dei Colli, Napoli, Italy

AIMS: The use of nucleotide-guided mesorectal excision) during Endoluminal Locoregional Resection by TEM reduced a local failure after transanal endoscopic microsurgery for residual rectal cancer limited to the wall (yp T0-2) and increases the lymph node harvest, No studirs showed if endoscopic tattoo I s usefull before surgery to define a sentinel node. METHODS: Inclusion criteria included 70 years with primary or post neoadjuvant chemoradiation (50.4–54 Gy and 5fluorouracil-based chemotherapy) with non metastatic rectal adenocarcinoma located no more than 8 cm from the anal verge or endorectal ultrasound- or magnetic resonance-staging c or ycT1-2, N0, probably candidated to TEM (transanal endoscopic microsurgery). The worklist may be underwent included: § FDG PET-TC. § Endoscopical peritumoral submucosa injection of 99 mtechnetium- marked nanocolloid and. § SPECT-TC identification of SN and TC guided multiple macrobiopsies and histological complete analysis; finally we compared histology and PET uptake.

AIMS: Endoscopic stenting for malignant colonic obstruction has advantages and disadvantages. The most frequent complications after insertion of a self-expandable metallic stent (SEMS) is reobstruction (migration when using covered stents and ingrown when using covered stents). Purpose our study was to compare the feasibility, efficacy and complication rate of two types new design stents. METHODS: From December 2012 to July 2016 in emergency state clinical hospital endoscopic stenting with X-ray control was carried out 45 patients with symptoms of bowel obstruction. We used two types of stent: double bare colorectal stent (n = 22) and double covered stent (n = 23) (S&G Biotech Inc., South Korea).

DESIGN: prospective, randomized, single-centre study. The mean age of the patients was 75.0 years (range 42–87 years). Fifteen patients were male and thirty were female. The most common obstructive lesion was in the sigmoid colon (62.2%), including the rectosigmoid junctions. Forty three patients (95.6 %) were suffered from primary colon cancer, two patients (4.4%) - extracolonic malignant lesions. Twenty nine patients stenting was performed as a palliative care, sixteen - as a bridge to surgery.

RESULTS: Technical success occurred 95.7 %. Clinical failure developed in 1 patient (2.2%) from the covered stent group. Early complication was observed in 1 patient (2.2%) - subcutaneous emphysema without pneumoperitoneum, using


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uncovered stent. One patient (2.2%) detected obstruction caused by tumor ingrown and overgrown (bare stent group). Stent migrations were not observed. The mean patency of the stent did not differ between the two groups (P = 0.5).

CONCLUSIONS: This study has reported the cases of longterm survival with compliable and acceptable condition treated by only local surgical excision and EMR. Conflict of Interest: None declared.

CONCLUSIONS: Double bare and double covered colorectal stents were feasibility and efficacy for relieving malignant colorectal obstruction. Reobstruction was rare complication in both stent groups. Necessary to continue to research for the accumulation of material from other centers. Conflict of Interest: None declared.

P304: ANAL MALIGNANT MELANOMA - TWO CASES REPORT AS A CHALLENGE FOR CLINICAL DECISION-MAKING 1

2

Jaedong Lee , Jeong Rok Lee , Ungchae Park

3

P305: MALIGNANT COLORECTAL POLYPS: LONG TERM OUTCOME POST ENDOSCOPIC THERAPY COMPARED TO SURGERY Ravinder Ogra, Ming Han Lim Middlemore Hospital, Gastroenterology, Auckland, New Zealand

AIMS: To investigate 3-year and 5-year survival of patients with malignant colorectal polyps (MCP) managed with endoscopic therapy (ET) or surgery.

1

Konkuk University Chungju Hospital, Internal Medicine, Konkuk University Chungju Hospital, and 3Konkuk University Chungju Hospital, Surgery, Chungju-si, Korea

2

AIMS: Anal malignant melanoma (AMM) is n uncommon disease. The principal complain is an anal mass and bleeding. In many cases, the disease is undetected or mistaken for a benign polyp or hemorrhoids until it reaches an advanced state. To date, a surgery remains the mainstay of treatment. Optimal treatment is still controversial. The aim of current report is to discuse about compliable and acceptable therapy of AMM. METHODS: We report two cases of AMM who had a different type of treatments. (1) A 77-year-old male with a history of cerebral infarction and hypertension presented with anal bleeding. Digital rectal examination revealed a palpable mass adjacent to the anal verge. EMR with adjuvant interferon therapy rather than surgical resection was performed. Urgent colonoscopy demonstrated a dark-colored, polypoid mass with a diameter of 1.5 cm and oozing hemorrhage adjacent to the anal verge.. In the other case. (2) a 71-year old man presented in our institution with anal pain, bleeding and tenesmus during the last 3 months. He referred personal history of diabetes mellitus and chronic renal failure. The colonofiberscopy showed an ulcero-vegetant lesion in the anal canal. The patient was treated by trans-anal excision because we considered that a palliative surgery might provide a better quality of life with symptomatic control.

RESULTS: (1) A 77-year-old malet has been disease-free for 5 years after EMR. Follow-up Colonoscopy and PET/CT scan have shown a no evidence of recurrence. (2) A 71-year old man has survived with nodular recurrent lesion around anal verge. The patient had a good control of anal pain with the prescribed analgesia.

METHODS: A prospective database of endoscopically excised MCP from 2000 to 2011 was maintained. Data was collected retrospectively from paper and electronic medical records. Attention was paid to the depth of invasion, tumour differentiation and lymphovascular invasion. Endoscopic mucosal resection was the main method of resection and specimens were pinned on cork where possible to allow better pathological assessment.

RESULTS: 56 patients with median age 73 (range: 46–90) had MCP excised endoscopically. Median polyp size was 25 mm (range: 5–60) with the majority being in the left colon (95%), tubular on histology (82%) and sessile (77%). 41% (23/56) of patients had surgery. Compared to the ET only group, patients who underwent surgery were significantly more likely to have higher tumour grade (76% vs 96%; P = 0.047), submucosal invasion (55% vs 91%; P < 0.001) and endoscopic resection margin < 1 mm (61% vs 91%; P = 0.01). There was no difference in age, tumour size, location and lymphovascular invasion between the two groups. 22% (5/23) of surgical specimens showed residual disease, all of which had endoscopic resection margin < 1 mm. 17% (4/23) had nodal involvement but no specific endoscopic or histologic predictors were identified in our small cohort of patients. There were 2 colorectal cancer related mortality and 1 treatment related mortality. Overall, the 3-year survival (76% vs 83%; P = 0.54) and 5-year survival (70% vs 65%; P = 0.73) were comparable between the ET only group and surgery group. CONCLUSIONS: In the absence of high risk features, malignant colorectal polyps excised endoscopically have similar medium and long term outcomes compared to those treated with surgical resection. Good tissue presentation may allow better pathological evaluation and potentially prevent unnecessary surgery. Conflict of Interest: None declared.




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P306V: THE POSSIBILITIES OF ENDOSCOPIC STENTING IN THE CASES OF LARGE BOWEL TUMOR OBSTRUCTION

P307: VALIDATION OF A NUQ® TRIAGE TEST TO IDENTIFY FIT POSITIVE INDIVIDUALS AT LOW RISK FOR COLORECTAL CANCER

Pavel V. Pavlov1, Victor V. Sokolov2, Petr V. Tsarkov3, Elena S. Karpova2, Inna A. Tulina3, Sergey K. Efetov3, Stepan S. Mirakyan1

Marielle Herzog1, Mark Eccleston1, Jake Micallef1, Dorian onore Josseaux1, Ib Jarle Pamart1, Brieuc Cuvelier1, Ele 2 Christensen , Hans Jørgen Nielsen2

1

1

I.M. Sechenov First Moscow State Medical University, Endoscopy, 2P.A. Herzen Moscow Oncology Research Institute, Endoscopy, and 3I.M. Sechenov First Moscow State Medical University, Coloproctology, Moscow, Russia

VolitionRx, Namur, Belgium and 2Hvidovre Hospital, University of Copenhagen, Department of Surgical Gastroenterology, Hvidovre, Denmark

AIMS: Validation of a combined NuQ® blood/numeric FIT AIMS: Searching the optimal tactics of colon decompression in the cases of large bowel tumor obstruction (LBTO). Colorectal cancer (CRC) is one of the most common kinds of oncopathology, with total LBTO-incidence about 10%. Despite it, management of patients with LBTO finally not solved. In Russia traditional method of decompression is colostomy. In rare cases with absence of comorbidity decompensation or bowel wall dystrophy/perforation surgents can performe palliative resection with primary anastomosis or formation of bypass. METHODS: We performed endoscopic stenting of CRC obstruction in 45 patients: 38 patients with primary or recurrent unresectable malignant tumor, complicated sub- or decompensated LBTO; in 3 patients indication for stenting was LBO, caused outside tumor compression; in 4 patients stenting was the first stage of radical surgery treatment. In 69% of cases the patients were male, average 67 years. In 45 patients we placed 55 self-expanding metal stents (SEMS). 85% stents were uncovered. Stenting was performed by two qualified endoscopist, with CO2 insufflation, under intravenous anesthesia.

RESULTS: In 96% of cases we achieved technical and in 93% clinical success with decompression of the colon. Minor complications were temporal tenesmus is 42% and chronic pain (VAScale 2–3 points) in 24% of cases. Tumor ingrowth with stent reobstruction occurred after 4–6 months of observation, and in 8 (18%) patients it required “stent-in-stent” procedure. In 3 (of 8) patients, covered SEMS were completely migrate. During stenting of 2 (4.5%) patients we occurred perforation of the colon wall, wich caused 1 patient’s death. CONCLUSIONS: Using of (especially covered) SEMS for prevention of LBTO is contraindicated due to the high risk of displacement. Stenting in conditions of bowel obstruction is a complex procedure and requires the experienced endoscopist. Despite the technical difficulties, stenting is the best alternative to colostomy. The concept of “bridge to surgery“ requires continued experience. Conflict of Interest: None declared.

score, previously developed using a training cohort of 1907 FIT positive patients, to reduce non-screen relevant colonoscopies (no colonoscopy findings or low risk adenomas) in an independent cohort of 2000 FIT positive individuals from an average risk screening population.

METHODS: Blinded serum samples taken from 2000 FIT positive individuals prospectively recruited from the Danish National CR screening program were analyzed (10 μL in duplicate) for circulating nucleosomes containing methylated DNA (normalized to total circulating nucleosomes) using NuQ® immunoassays.

RESULTS: In the 1907 FIT positive training set, a single, age adjusted NuQ® assay (normalized to total nucleosomes) combined with FIT score identified a low-risk subset of 477 individuals (25%) for whom colonoscopy could be avoided whilst detecting 96.6% of CRCs and 88.5% of High Risk Adenomas (HRA). A 25% reduction in over colonoscopy would miss 4 cancers and 29 HRA in the 1907 training cohort. However, 33%, more people could potentially be screened by FIT without increasing the total number of colonoscopies performed - potentially detecting 34 additional CRC cases. Validation of these data in a further independent study will be presented. CONCLUSIONS: Stool Screening for CRC is widely adopted across European and other countries with proven reduction in mortality but can place significant strain on limited colonoscopy capacity. Combining a single, age adjusted NuQ® blood score with FIT score could reduce unnecessary colonoscopies in FIT positive individuals with minimal reduction in sensitivity. Screening throughput and overall detection of CRC and High Risk Adenomas could therefore be increased where colonoscopy capacity is a limiting factor. Clinical validation of this approach would provide an affordable, accessible approach to improve stool based screening capacity ultimately detecting more early stage cancers and saving lives. Conflict of Interest: The authors are employees, consultants or have received research funding from VolitionRx.


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P308: THE MANAGEMENT OF ACUTE MALIGNANT LEFT-SIDE LARGE-BOWEL OBSTRUCTION Masayuki Isozaki, Noboru Yokoyama, Akiko Ueno, Genki Tsukuda, Kunio Asonuma, Kai Matsuo, Syuei Arima, Naoyuki Uragami, Haruhiro Inoue Showa University Koto-Toyosu Hospital, Digestive Disease Center, Tokyo, Japan

AIMS: Acute surgery in the management of malignant left-side colorectal obstruction is high morbidity and mortality. In palliative treatment, several approaches have been widely reported. We experienced three approaches as a bridge to surgery, transverse colostomy, trans-anal decompression tube (TADT) and self-expanding metal stent (SEMS). We considered short-term outcomes of each method. METHODS: Sixteen patients with acute left-sided obstructive colorectal cancer were assigned to be received colostomy, TADT or SEMS as a bridge to elective surgery.

RESULTS: Transverse colostomy was attempted for 3 patients. In two-term operation, they were underwent singleincision sigmoid colectomy by using advantage of colostomy closure site. Four patients were inserted TADT under x-ray guiding. SEMS was underwent for 9 patients and failed in one patient with technical problem. Eight patients who had good decompression, were electively underwent one-term laparoscopic surgery. But there were some complications such as perforation due to inserting procedures. CONCLUSIONS: Transverse colostomy could be created safely, and single-incision sigmoid colectomy would be low invasive surgery. The patients who had good decompression by TADT and SEMS could be underwent one-term laparoscopic surgery. Therefore, the occurrence of incidence, including perforation, was not low rate. There are some tips and points to be taken into consideration to achieve safe procedures. These procedures should be used in treatments of obstructive colorectal cancer would be increased in the future. The correct colorectal decompression method should be selected according to the case for each clinical condition. Conflict of Interest: None declared.

P309: INCIDENCE OF SYNCHRONOUS POLYPS AND TUMORS IN PATIENTS WITH COLORECTAL CANCER A SINGLE CENTER EXPERIENCE FROM A LOW PREVALENCE AREA FOR COLORECTAL CANCER Prachi Patil1, Sridhar Sundaram1, Mukund Virparia1, Shaesta Mehta1, Pravir Gambhire1, Avanish Saklani2 1

Tata Memorial Hospital, Department of Digestive Diseases and Clinical Nutrition, and 2Tata Memorial Hospital, Department of Surgical Oncology, Mumbai, India

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 AIMS: Synchronous colorectal tumors are seen in 2–6 % patients with colorectal cancer (CRC) and synchronous adenomatous polyps seen in 30%. Our aim was to study the incidence of synchronous adenomatous polyps and tumors in patients with CRC at a referral oncology center in India which is a country with a low incidence of CRC. METHODS: Retrospective review of case records of patients presenting with newly diagnosed CRC to Tata Memorial Centre, Mumbai between August 2013-July 2014 was done. Details of laboratory investigations, endoscopy and pathology were noted.

RESULTS: 800 patients with newly diagnosed CRC (adenocarcinoma) were analyzed, of which 517 (64%) were male. The most common site was anorectum (54%). 29% patients were metastatic at presentation. Baseline colonoscopy was done in 646 patients, of which 301 (47%) were complete colonoscopies. Of these, 6 patients (2%) has synchronous colorectal cancer and 42 (13.9%) had synchronous polyps. 22 of these polyps were tubular/ villous on pathology giving an incidence of 7.3%. 345 patients had an incomplete colonoscopy, commonest reason being stenotic tumor (74%) and poor preparation (7.5%). There were 3 synchronous colorectal cancers (0.8%) and 16 polyps (4.6%) with 12 polyps (2.9%) being tubular/ villous. Overall 9 patients (1.4%) had synchronous colonic malignancy and 58 patients (9%) had synchronous polyps at baseline assessment (23- multiple polyps; 9- polyposis syndrome). Of these, 34 (5.2%) patients had tubular adenomas. Adenomas with advanced pathology (AAP) were seen in 7 patients (1%) with 3 having colonic polyposis. CONCLUSIONS: The incidence of synchronous colorectal cancers and adenomatous polyps in Indian patients with CRC is 2% and 7.3% respectively in patients undergoing complete baseline colonoscopy. These rates are lower than those described from western populations. This may be a reflection of low CRC rates in India. Limitation of our study is retrospective nature of study and large number of incomplete colonoscopies. Conflict of Interest: None declared.

P310: DIFFUSE LARGE B CELL LYMPHOMA OF COLON CAUSING COLO-DUODENAL FISTULA: A CASE REPORT Partha Pal, Hrushikesh Chaudhari, Anuradha Sekharan, Manu Tandan, Rao V. Guduru, D. Nageshwar Reddy Asian Institute of Gastroenterology, Gastroenterology, Hyderabad, India

AIMS: Colonic lymphoma causing malignant fistula of bowel is an exceeding rare entity. Colonic lymphoma represents 0.5 percent of colonic malignancies. Malignant bowel fistula is often caused by adenocarcinoma. We report a case of colonic diffuse large B cell lymphoma lymphoma of ascending colon causing duodeno-colic fistula which was diagnosed by endoscopic biopsy.


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 METHODS: A 72 years old male presented with chronic diarrhea, significant weight loss for 9 months. He was referred from local hospital where he was treated as a case of colitis as colonoscopic biopsy revealed non-specific inflammation. He had one episode of feculent vomiting and had high fever prior to admission. Clinically he had lump in right upper quadrant of abdomen. On evaluation, he had anemia, leucocytosis with left shift. Computed tomography (CT) abdomen showed large duodenal mass involving duodenum and ascending colon with aneurysmal dilatation of bowel, right hydronephrosis and large necrotic lymph node node at right external iliac region. Esophago-gastro-duodenoscopy (EGD) showed esophageal candidiasis, duodenum opening into feces filled ascending colon. Endoscopic biopsy was taken from margin of the fistula which revealed high grade non-hodgkin’s lymphoma - diffuse large B cell lymphoma (immunohistochemistry showed positivity to CD20 and Ki67 index of 70%).

RESULTS: Laparotomy was planned but the patient developed septic shock inspite of broad spectrum antibiotics. His condition gradually deteriorated and the patient succumbed to sepsis before any definitive therapy could be planned.

CONCLUSIONS: Colonic lymphoma is an extremely rare entity which should be considered in a case of inter-bowel loop fistula. Presentation may be vague with diarrhea, malnutrition and fever. Early aggressive management including laparotomy may be required to salvage patients with this highly fatal condition as endoscopic biopsy is often unrevealing and misleading. Conflict of Interest: None declared.


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its location, size, gistological structure and the vascular pattern. Capillar pattern IIIb (Sano) in flat and flat-deepened neoplasia, the absence of elevation at the injection of the solution into submucosal layer are considered to be contra-indications of endoscopic treatment.

RESULTS: After diagnosing colorectal neoplasia and a positive decision in favour of endoscopic method of treatment we remove neoplasia and mark the bowel wall. Then we estimate radicality of operation by the following criteria: morphological structure, depth of invasion, resection edges, involvement of lymphatic and blood vessels. Depending on the results patients are either operated on, or observed. The period of observation lasts from 3 months to 4.5 years. We analyzed the frequency of complications and relapses after endoscopic treatment and found out about 3.8% and 1.5% cases respectively. CONCLUSIONS: The essence of algorithm consists in optimal choice of patient routing and methods of treatment colon neoplasia, which depends on the results of postoperative morphological assessment of remote preparation. Thus, the given investigation showed that colon neoplasia endoscopic treatment is a highly effective method with low traumatism, low rate of complications and relapses at a correct choice of algorithm. Conflict of Interest: None declared.

P312: ADENOMA RECURRENCE AFTER PIECEMEAL COLONIC EMR IS PREDICTABLE: THE SYDNEY EMR RECURRENCE TOOL (SERT) David Tate, Lobke Desomer, Amir Klein, Michael Bourke, Australian Colonic EMR Resection Study Group

COLON AND RECTUM: ENDOSCOPY: COLORECTAL POLYPS

Westmead Hospital, Sydney University, Sydney, Australia

P311: WAYS AND METHODS OF ENDOSCOPIC TREATMENT OF COLORECTAL NEOPLASIA

AIMS: Endoscopic mucosal resection (EMR) is the primary treatment of large colonic laterally spreading lesions (LSLs). Residual or recurrent adenoma (RRA) is a major limitation. We aimed to identify a robust method to stratify risk of RRA.

Alexander Mitrakov1, Elena Golodyuk2, Nina Mitrakova3, Raisa Smirnova1, Vladimir Terekhov1 1

Nizhny Novgorod Regional Clinical Oncological Center, Nizhny Novgorod, 2Republic Clinical Hospital, Yoshkar-Ola, and 3Republican Clinical Hospital, Endoscopy, Yoshkar-Ola, Russia

AIMS: Development of algorithm of treatment patients with colorectal neoplasia. METHODS: 350 patients (average age 59) with colorectal neoplasia were subjected to endoscopic treatment. The choice of endoscopic methods varied from mucosal resection - 35.5%, fragmentary mucosal resection - 25%, loop electroexcision 23.5% to submucosal layer dissection - 12.5% and TME-ESD 3.5%. The choice of method depended on the type of neoplasia,

METHODS: Prospective multicentre data on consecutive LSLs ≥20 mm removed by piecemeal EMR from eight Australian tertiary centres was included (9/2008 until 05/ 2016). A logistic regression model for endoscopically determined recurrence (EDR) was created on half of the cohort to yield the Sydney EMR Recurrence Tool (SERT), a four-point score to stratify the incidence of RRA based on characteristics of the index EMR. SERT was validated on the remainder of the cohort.

RESULTS: Analysis was performed on 1178 lesions that underwent first surveillance colonoscopy (SC1) (median 4.9 months, IQR 4.9 to 6.2). EDR was detected in 228/1178 patients (19.4%). LSL size ≥40 mm (OR 2.47, P < 0.001), intraprocedural bleeding (OR 1.78, P = 0.024) and high grade dysplasia (OR 1.72, P = 0.029) were identified as independent


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predictors of EDR and allocated scores of 2, 1 and 1 respectively to create SERT. SERT=0 had a negative predictive value of 91.3% for recurrence at SC1 and SERT was shown to stratify RRA to specific follow up intervals using Kaplan Meier curves (Log-Rank P < 0.001).

Kudo Neoplastic Pattern (KPP)

Correct Endoscopic Assessment n = 169

II

12/15

III/IV

146/152

V

1/2*

Accuracy (95% CI)

CONCLUSIONS: Guidelines recommend SC1 within 6 months of EMR. SERT accurately stratifies the incidence of RRA post EMR. SERT=0 lesions could safely undergo first surveillance at 18 months, whereas SERT 1–4 lesions require surveillance at 6 and 18 months. Clinicaltrials.gov NCT01368289. Conflict of Interest: None declared.

P313: ACCURACY OF ENDOSCOPIC IMAGING TO DETERMINE THE KUDO PATTERN OF LATERALLY SPREADING COLONIC LESIONS David Tate, Lobke Desomer, Halim Awadie, Michael Bourke Westmead Hospital, Sydney University, Sydney, Australia

AIMS: Expert opinion suggests that the discrimination of pit pattern of colorectal lesions, first described by Kudo (Kudo neoplastic pit pattern, KPP), requires a chromic dye combined with magnification endoscopy. Advances in endoscopic imaging may mean that chromendoscopy is not necessary for the discrimination of the KPP. METHODS: The study aimed to evaluate the diagnostic accuracy of high definition white light (HDWL) and narrowband imaging (NBI) for the discrimination of KPP to predict lesion histopathology without chromendoscopy. Amongst a prospective observational study of patients referred for WFEMR of laterally spreading lesions (LSL) >20 mm, successive lesions were analysed prior to resection for KPP using HDWL and NBI including the ‘near focus’ magnification mode where available. Olympus H180/HQ190 endoscopes were used throughout. Lesion histopathology was determined later by two expert gastrointestinal histopathologists. KPP II, III+IV and V were correlated to sessile serrated adenoma, tubular adenoma/tubulovillous adenoma and invasive cancer respectively. Since the therapeutic approach for KPP III/ IV is identical these were logically grouped together. The primary outcome was congruence of endoscopic pit pattern assessment with histology.

RESULTS: From January 2015 to April 2016, 162 patients were referred for WFEMR at a single tertiary referral endoscopy centre. Analysis of Kudo pit pattern was available for 169 lesions. Endoscopic assessment of the KPP was correct in 159/ 169 (94.1%) cases overall and specific data on accuracy of individual KPP is presented in table 1 [Table 1; Correct endoscopic assessment of KPP].

80% (51.3–94.7) 96.1% (91.2–98.3)

Histopathology where endoscopic assessment of KPP was incorrect n = 10 Tubular, 1 (33%) TVA, 2 (66%) SSA-ND, 3 (50%) SSA-D, 2 (33.3%) Invasive Cancer, 1 (16.7%) TVA HGD, 1

CONCLUSIONS: Kudo pit pattern can be reliably determined by advanced endoscopic imaging in the majority of cases. KPP III and IV, suggesting endoscopic resectability, were correctly predicted in over 95% of cases. Conflict of Interest: None declared.

P314: SESSILE SERRATED COLONIC POLYPS ARE NOT ASSOCIATED WITH HIGHER RATES OF RESIDUAL ADENOMA AFTER EN BLOC ENDOSCOPIC MUCOSAL RESECTION Vinay Chandrasekhara, Amol Agarwal, Frank Scott, Sidyarth Garimall, Michael Kochman, Nuzhat Ahmad, Gregory Ginsberg University of Pennsylvania, Philadelphia, USA

AIMS: Sessile serrated adenomas/polyps (SSP) have been associated with higher rates of incomplete resection after snare polypectomy compared to tubular adenomas (TA). The aim of this study is to determine if en bloc endoscopic mucosal resection (EMR) of SSPs is associated with higher rates of residual neoplasia at surveillance colonoscopy compared to tubular adenomas. METHODS: A retrospective review of consecutive patients referred for colonic EMR from 2005 to 2013 was performed. EMR was performed using the inject-and-cut technique with an en bloc resection. Procedural information, specimen histology and subsequent surveillance colonoscopy data were recorded.

RESULTS: 308 patients underwent en bloc EMR for 319 colonic polyps, including 208 TA and 111 SSPs. 256 (80%) of the histopathological reports commented on presence of neoplasia at the resection margins. 33/71 SSPs (46.5%) involved the margins icompared to 68/186 TA (37%; P = 0.16). 13 of the 167 cases (7.8%) with available surveillance colonoscopy data had residual adenoma at a median follow-up 13 months (IQR 8– 22) including 2/55 SSPs (3.5%) and 11/112 TA (9.8%; P = 0.22). Residual adenoma was noted in 4/79 (5.1%) with clear margins compared to 6/66 (9.1%; P = 0.51) with positive margins.


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 CONCLUSIONS: In this series, en bloc EMR for referred colonic adenomas is associated with 7.8% rate of residual adenoma and warrants close surveillance, even if the resection margins are clear. Although SSPs are associated with high rates of neoplasia extending to the resection margin, this did not result in higher rates of residual SSP at surveillance colonoscopy. Injection-assisted EMR may be the preferred resection method for flat SSPs less than 20 mm. Conflict of Interest: None declared.

P315: PANCHROMOCOLONOSCOPY AMONG RESIDENTS OF SIBERIA: EPIDEMIOLOGICAL ASPECTS OF COLORECTAL NEOPLASMS Pavel Frolov, Sergey Zaikin Regional Clinical Center of Miners’ Health Protection, Endoscopy, Leninsk-Kuznetsky, Russia

AIMS: Assessing opportunities of routine panchromocolonoscopy with indigocarmine in the identification of flat and diminutive colorectal neoplastic lesions. METHODS: The prospective clinical study included 155 patients, who underwent first-time total colonoscopy. The control group of 119 patients (age of 56.3 1) were performed the standard examination using videocolonoscope in white light. For 36 patients of the main group (age of 53.4 2) with panchromocolonoscopy the 0.2 % indigocarmine spraying with spray catheter was used.

RESULTS: A total of 148 neoplasia was identified: 58 - in the main group, 90 - in the controls. The main group had more flat neoplasia < 5 mm (P = 0.0247). The size of neoplasia in the main group: diameter - 7.1 1.4 mm, height - 2.2 1.4; in the control group: diameter - 8 0.9 mm, height - 4.5 0.5 mm. The histological study identified adenoma in 69 % and 82.3 % (P = 0.0613), non-neoplastic lesions - 29.3 % and 13.3 % (P = 0.0168), adenocarcinoma - 2.8 % and 3.4 % (P = 0.8621), respectively. Neoplasia of IIa type was identified in 69 % and 16.7 % (P < 0.0001), lesions of Ip type - 0 % and 1.3 % (P < 0.0001), Is type - 22.4 % and 62.2 % (P = 0.0037), respectively. The number of neoplasia, adenoma and non-neoplastic lesions for 1 patient was higher in panchromocolonoscopy than in the control group (1.6, 1.1, 0.5 vs 0.8, 0.6, 0.1) (P < 0.001). CONCLUSIONS: Compared to the standard technique panchromocolonoscopy allows to identify small and flat neoplasia more frequently, demonstrates the high rate of frequency of adenoma as the precursors of colorectal cancer development. Panchromocolonoscopy with indigocarmine is the economic and simple method for identification of colorectal neoplastic lesions. Conflict of Interest: None declared.


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P316: THE RISK FACTORS OF DYSPLASIA AND VILLOUS TISSUE IN DIMINUTIVE COLORECTAL POLYPS Natalia Ageykina1, Mikhail Knyazev2, Vladimir Duvansky3 1

Medical Rehabilitation Centre MER RF, 2Medical Rehabilitation Centre MER RF, RUDN University, and 3RUDN University, Moscow, Russia

AIMS: To assess the prevalence of dysplasia and villous tissue in diminutive colorectal polyps (DCP). METHODS: We used high-definition colonoscopes Olympus «Exera 3», «Lucera» (HD, NBI, ZOOM). A total of 255 DCP, up to 5 mm, were detected in 172 patients (106 women and 66 men). We analyzed the endoscopic characteristics of the DCP and the distribution of them in the colon. All polyps were removed endoscopically and were subject to morphological studies.

RESULTS: 64 (33.5%) polyps were of inflammatory nature; 191 polyps were of hyperplastic or dysplastic structure: 91 (35.7 %) DCP were of serrated histological structure and 100 (39.2 %) DCP were of non-serrated histological structure; 107 (42%) polyps had dysplasia; 8 (3%) cases had villous tissue. The distribution of localization was: 110 (43.1%) DCP present on the right side of the colon, 48 (18.8%) with dysplasia; 145 (56.9 %) DCP present on the left side of the colon, 59 (23.1%) with dysplasia. Analysis of the relative risk of DCP with dysplasia showed RR = 1.072 (>1) of Se = 0.45 and Sp = 0.58 P > 0.05. We analyzed the relative risk of tubulovillous adenomas based on their location in the colon. 3 were found to be located on the right, whereas 6 were found on the left. Analysis results showed RR=2.28, DI [0.46–11.06] of Se=0.75 and Sp=0.43 P > 0.05. CONCLUSIONS: The likelihood of the development of tubulovillous adenomas is almost 2 times higher when located on the left of the colon. Given the high prevalence of dysplasia, including villous tissue in DCP (42%), as well as the difficulty of diagnosis endoscopically, endoscopic removal of DCP is a rational approach to prevent the development of colon cancer. Conflict of Interest: None declared.

P317: PREDICTORS OF POLYP RECURRENCE AND COMPLICATIONS WHEN MANAGING LARGE COLORECTAL POLYPS ENDOSCOPICALLY Ravinder Ogra, Ming Han Lim Middlemore Hospital, Gastroenterology, Auckland, New Zealand

AIMS: 1) Assess polyp recurrence within 12 months. 2) Identify predictors of polyp recurrence. 3) Evaluate procedural complications.


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METHODS: A prospective database of endoscopically excised large polyps (LP i.e. ≥20 mm) from 2000 to 2016 was maintained. Data was collected retrospectively from paper and electronic medical records.

RESULTS: 709 LP with mean size 31 mm (range: 20–120) were excised from 581 patients, median age 71 years (range: 16–94). Majority of LP were sessile (70%), in the left colon (68%) and tubulovillous adenoma on histology (58%). 11% were malignant. 74% sessile LP were removed by endoscopic mucosal resection while 68% pedunculated LP were removed by snare. Argon plasma coagulation (APC) use was more common for sessile LP than pedunculated LP (19% vs 1%, P < 0.001). Overall, polyp recurrence within 12 months was 23% (106/467). Multivariate logistic regression analysis showed that a sessile polyp morphology was the most important predictor of polyp recurrence (odds ratio [OR] 6.85, 95% confidence interval [CI] 2.85 to 16.51, P < 0.001) compared with APC use (OR 2.81, 95% CI 1.54 to 5.114, P < 0.001) or polyp size (OR 1.05, 95% CI 1.03 to 1.07, P = 0.001). Bleeding was the most common complication at 7% with the presence of high grade dysplasia being the only independent risk factor (OR 4.2, 95% CI 1.63 to 10.82, P = 0.003). Rates of procedural, early (within 24 h) and delayed (after 24 h) bleeding were 5%, 1% and 2% respectively. Other complications include failed endoscopic management (1.5%), post polypectomy syndrome (1.4%) and bowel perforation (1.4%). 4 patients required emergency surgery for endoscopic complications with 1 subsequent death. CONCLUSIONS: Endoscopic management of large colorectal polyp was safe and effective with acceptable recurrence rates within 12 months. In our experience, APC use did not seem to reduce recurrence. Conflict of Interest: None declared.

P318: ENDOSCOPIC MANAGEMENT COLOCOLIC INTUSSUSCEPTION FROM GIANT COLORECTAL POLYPS IN 2 ADULTS

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 upstream large bowel and distal small bowel obstruction. Flexible sigmoidoscopy on day 1 revealed a 70 mm pedunculated polyp with a thick stalk in the descending colon causing intussusception which was successfully reduced endoscopically with associated symptomatic improvement. The giant polyp was removed piecemeal endoscopically with endoscopic mucosal resection five days later and he was discharged on day 7. A Peutz-Jeghers type hamartomatous polyp was confirmed on histology.Case 2: 90 year old Caucasian woman with advanced Alzheimer’s dementia admitted with 3 day history of abdominal distension and anorexia. On presentation, her abdomen was distended and tympanic but non tender. AXR suggested possible sigmoid pathology with large bowel obstruction. A proximal descending colocolic intussusception with associated large bowel obstruction was confirmed on CT abdomen. Flexible sigmoidoscopy on day 2 revealed a circumferential, obstructing, giant (~120 mm), semi-pedunculated sigmoid polyp which was debulked with a hot snare. Tubulovillous adenoma with low grade dysplasia was confirmed on histology. As she was not a surgical candidate, further endoscopic debulking was performed on day 5 and day 15 with resolution of intussusception and large bowel obstruction. She was discharged to a private hospital on day 49.

CONCLUSIONS: Colocolic intussusception secondary to giant colorectal polyps can be successfully managed endoscopically in selected cases. Conflict of Interest: None declared.

P319: LARGE SESSILE HIGH GRADE DYSPLASTIC COLORECTAL POLYPS CAN BE MANAGED SUCCESSFULLY ENDOSCOPICALLY Ravinder Ogra, Ming Han Lim Middlemore Hospital, Gastroenterology, Auckland, New Zealand

Ravinder Ogra, Ming Han Lim Middlemore Hospital, Gastroenterology, Auckland, New Zealand

AIMS: To evaluate polyp recurrence rate within 12 months and medium term colorectal cancer free survival. Attention was paid to the persistence of HGD on recurrence.

AIMS: To describe successful endoscopic management of Colocolonic intussussception from Giant Colonic polyps.

METHODS: A prospective database of endoscopically excised

METHODS: This is description of the endoscopic techniques used for management of these giant polyps.

RESULTS: Case 1: 18 year old Samoan man admitted with a 5 day history of increasing colicky abdominal pain associated with vomiting and bloody diarrhoea. On presentation, he had generalised abdominal tenderness with localised peritonism in the right lower quadrant, blood on PR examination and elevated WCC (12.5 x10^9/L). Abdominal X-ray (AXR) suggested possible obstruction at the descending colon. CT abdomen confirmed a distal descending colocolic intussusception with evidence of

large (≥20 mm) sessile colorectal polyps with high grade dysplasia (HGD) from 2000 to 2013 was maintained. Data was collected retrospectively from paper and electronic medical records.

RESULTS: A total of 101 high grade dysplastic large sessile colorectal polyps with mean size 39 mm (range: 20–120 mm) were endoscopically excised from 94 patients. 5 patients did not receive endoscopic follow up due to deaths unrelated to procedure/colorectal cancer within 12 months. Median endoscopic follow up was 35 months (range: 4–141 months). Majority of polyps excised were tubulovillous adenoma (81%) and found in the rectum (42%). 52% had concurrent polyps, 19%


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 had concurrent large polyps, 7% had concurrent adenocarcinoma and 6% had a past history of colorectal cancer. Overall, 75 polyps (78%) were successfully eradicated endoscopically, median 1 procedure (range: 1–4 procedures) and 9 patients (9%) required surgery. Persistent polyp recurrence occurred in 12 polyps (13%), requiring a median of 4 procedures (range: 1–7 procedures) over a median follow up period of 31 months. Polyp recurrence within 12 months was 41% (37/91). Endoscopic therapy successfully downstaged the degree of dysplasia 51% (19/37) and cleared 51% (19/37) of recurrent polyps. There were 11 non colorectal cancer related deaths and no colorectal cancer diagnosed within 3 years of follow up. However, 3 colorectal cancers were diagnosed at the location of previous endoscopic excision at 37, 58 and 59 months respectively.

CONCLUSIONS: Large sessile colorectal polyps with HGD can be managed safely and successfully endoscopically. Close follow up is paramount due to high short term polyp recurrence in these high risk patients. Conflict of Interest: None declared.

P320: DETECTION RATES OF TRADITIONAL AND SESSILE SERRATED ADENOMAS DURING SCREENING COLONOSCOPY AND FACTORS PREDICTING THEIR DETECTION Sreekar Vennelaganti1, Prashanth Vennalaganti1, Abhiram Duvvuri1, Sravanthi Parasa1, Babak Gachpaz1, Anusha Vittal1, Ajay Bansal1, Tarun Rai1, Abhishek Choudhary1, Kevin Kennedy1, Neil Gupta2, Prateek Sharma1 1

Kansas City VA Medical Center, Kansas City, and 2Loyola University, Maywood, USA

AIMS: High adenoma detection rate (ADR) has been associated with a reduction in missed colo-rectal cancer (CRC). Although up to 30 % of CRC arise from sessile serrated adenoma/polyps (SSA), its prevalence and factors predicting their occurrence are not well defined. Our aim was to determine the ADR and SSA-ADR and factors predicting their detection on screening colonoscopies.

METHODS: Data were retrospectively collected from an endoscopy database of a single tertiary referral center of the patients who underwent average risk screening colonoscopy in adults from January 2013 to November 2015. Demographic data (Age, race, gender, BMI, use of medications), quality indicators (ADR, bowel preparation, withdrawal time), types of endoscopes used (standard definition, high-definition) were collected. Univariate associations were tested with Student’s ttest and chi-square where appropriate and multivariable predictors were determined with logistic regression.


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was 4% (95% CI 3, 5). Of the total 690 colonoscopies with polyps removed, 6.7% were SSA. On multivariate analysis, increasing age (OR per 5-year increase: 1.13 (1.02, 1.26), P 0.02), smoking (OR: 1.39 (1.01, 1.92), P 0.04) and withdrawal time (OR per 1minute increase: 1.09 (1.08, 1.11), P < 0.0001) were associated with a significantly higher ADR. Significant increase in SSA detection rates were seen with longer withdrawal time (OR per 1-min increase: 1.04 (1.02, 1.06), P 0.0002).

CONCLUSIONS: Our study shows that the adenoma detection rate and SSA detection rates are high among Caucasian men and within the reported range from previous studies. Increasing age, smoking and longer withdrawal times were associated with higher adenoma detection rates. SSA detection rates significantly improved with longer withdrawal time. Conflict of Interest: None declared.

P321V: COLD AVULSION AND SNARE TIP SOFT COAGULATION (CAST) FOR THE MANAGEMENT OF NON-LIFTING LARGE LATERALLY SPREADING COLORECTAL LESIONS Farzan F. Bahin1,2, David J. Tate1, Michael J. Bourke1,2 1

Westmead Hospital, Gastroenterology and Hepatology, Westmead, and 2University of Sydney, Medicine, Sydney, Australia

AIMS: Non-lifting large laterally spreading colorectal lesions (NL-LSL) are challenging to remove endoscopically and often require referral for surgery. We aim to demonstrate the technique of Cold Avulsion and Snare Tip Soft Coagulation (CAST) for the management of such lesions. METHODS: Following submucosal injection initial resection is performed with a stiff thin wire snare. Adjacent normal mucosa is excised by endoscopic mucosal resection to isolate the lesion and free the lateral margins. After complete snare resection all remaining visible adenoma was removed by cold forceps avulsion. The avulsion site and its margins are treated with controlled thermal ablation using snare tip soft coagulation (ERBE effect 4, 80 W).

RESULTS: Video demonstration. CONCLUSIONS: CAST appears to be a a safe and effective surgery sparing therapy for NL-LSL. It is simple to use, low-cost and does not require additional equipment. Conflict of Interest: None declared.

RESULTS: Of 1085 patients who underwent screening colonoscopies, majority were males 94.7%, Caucasians 71%, and mean age 63.6 years. The ADR among patients undergoing average risk screening colonoscopy was 64% (95% CI 61, 67) and SSA-DR


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P322: COMPARATIVE ANALYSES OF 572 LATERALLY SPREADING TUMORS (LST) LESIONS TREATED WITH ENDOSCOPIC MUCOSAL RESECTION TECHNIQUE (EMR) Claudio Rolim Teixeira1, Leonardo Menegaz Conrado2, Luciana Filchtiner Figueiredo1,2, Michele Lemos Bonotto2, Carlos Renato Frasca Rodrigues2, Julio Carlos Pereira-Lima2, Sidia Maria Callegari-Jacques3 1

Hospital Moinhos de Vento, Endoscopy Unit, 2FUGAST, Endoscopy Unit, and 3Universidade Federal do Rio Grande do Sul, Statistics Department, Porto Alegre, Brazil

AIMS: Evaluate whether the LST’s morphology subtypes (granular - LST-G; non-granular - LST-NG), as well as other characteristics such as size, location and pit pattern classification can correlate with mortality rate, recurrence rate, bleeding, perforation and EMR modality. METHODS: A total of 572 patients with colorectal LST’s treated with the EMR lift-and-cut technique at our institution from November 2000 to June 2015 were evaluated. The size of the lesions was estimated in millimeters. Pit pattern was determined according to Kudo’s classification. Bleeding, perforation and en bloc or piecemeal resections were also reported. Follow-up was obtained in 277 patients. Statistical analyses were performed using Wilcoxon-Mann-Whitney and qui-square tests.

RESULTS: 331 LST-G and 241 LST-NG lesions were analyzed. There were no diferences in groups related to gender (P = 0.49) and age (mean age 64.5 and 62.7, respectivelly). LST-G (mean size 42.8 mm) was larger than LST-NG (mean size 18.1), P < 0.001. In the LST-NG group, 80% of the lesions had up to 20 mm, with 55% located in the transverse colon. In the LST-G group, 73% of the lesions were larger than 20 mm, with 76% located in the rectum (P < 0.001). Pit pattern IIIL was found in 52% of the LST-NG. Pit pattern IV was present in 70% of the LST-G (P < 0.001). Bleeding rate was 12% in LST-NG group and 18% in the LST-G group (P = 0.097). We had two perforations in the LST-G group. En bloc resection rate was higher in the LST-NG group (68% vs 27% P < 0.001) with a recurrence rate of 17% in the LST-NG lesions and 41% in the LST-G lesions (P < 0.001). We had no mortality reported. CONCLUSIONS: LST-G subtype is related to larger tumors, leading to a higher risk of complications and recurrence rate. Nevertheless, most of these lesions can be successfully cured with piecemeal EMR, with low morbidity and mortality rates. Conflict of Interest: None declared.


P323: COLD FORCEPS AVULSION (CFA) WITH ADJUVANT SOFT COAGULATION (STSC) FOR IS SAFE AND EFFECTIVE TO COMPLETELY REMOVE NONLIFTING LATERALLY SPREADING LESIONS OF THE COLON David Tate, Farzan F Bahin, Lobke Desomer, Vikas Gupta, Mayenaaz Sidhu, Michael Bourke Westmead Hospital, Sydney University, Sydney, Australia

AIMS: Non-lifting (NL) large laterally spreading colorectal lesions (NL-LSL) are challenging to resect endoscopically and often necessitate surgery. Safe and effective endoscopic management of NL-LSL has not been described. METHODS: Amongst a prospective study of patients referred for endoscopic mucosal resection (EMR) of LSL>=20 mm, LSL which could not be completely resected by snare due to NL were labelled NL-LSL. These were divided into previously attempted NL-LSL (PANL-LSL) and na€ıve, NL LSL (NNL-LSL). Such lesions had completion of resection using a standardized approach with CFA and STSC. CFA was first performed to remove all visible NL adenoma. The avulsion site and its margins were then treated with STSC (ERBE effect 4, 80 W). The primary outcome was endoscopic and histological evidence of adenoma clearance.

RESULTS: From January 2012 to April 2016, 83 NL-LSL and 650 standard LSL underwent EMR. PANL-LSL (n = 33) were smaller and more likely to be non-granular (62.5 vs 33.9%, P = 0.003) than standard LSL. NNL (n = 50) were also more likely to be non-granular (46 vs 33.9%, P = 0.12) and were associated with previous biopsy (32 vs 13.8%, P = 0.001) and carbon particle suspension injection within 10 mm of the lesion (26 vs 3.8%, P < 0.001). The technique was successful in all cases with no difference in adverse events vs standard EMR. Endoscopic recurrence at SC1 was not significantly different for PANL-LSL treated with CFA and STSC than LSLs treated with complete snare excision, whereas NNL-LSL recurred more frequently (16.0 vs 12.2%, P = 0.578 and 28.2 vs 12.2%, P = 0.005 respectively). CONCLUSIONS: CFA and adjuvant STSC is a safe, effective and surgery sparing therapy for the majority of NL-LSL. Early recurrence rates at SC1 are comparable between PANL-LSL and standard LSL. NNL-LSL recur more frequently. Non granular LSLs were over-represented in both groups. Conflict of Interest: None declared.




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P324: COMPARATIVE ANALYSIS OF ENDOSCOPIC AND HISTOPATHOLOGICAL FEATURES OF SUPERFICIAL COLORECTAL LESIONS TREATED BY ENDOSCOPIC MUCOSAL RESECTION (EMR)

P325: TWO STAGE ENDOSCOPIC MUCOSAL RESECTION (TSEMR) OF COLONIC LATERALLY SPREADING LESIONS (LSL) IS SAFE AND EFFECTIVE AS A SALVAGE STRATEGY AFTER FAILED EMR

Claudio Rolim Teixeira1, Leonardo Menegaz Conrado2, Luciana Filchtiner Figueiredo1,2, Michele Lemos Bonotto2, Carlos Renato Frasca Rodrigues2, Julio Carlos Pereira-Lima2, Sidia Maria Callegari-Jacques3

David Tate1, Lobke Desomer1, Halim Awadie1, Mayenaaz Sidhu1, Luke Hourigan2, Alan Moss3, Michael Bourke1

1

Hospital Moinhos de Vento, Endoscopy Unit, 2FUGAST, Endoscopy Unit, Porto Alegre, Brazil and 3Universidade Federal do Rio Grande do Sul, Statistics Department, Porto Alegre, Brazil

AIMS: To compare endoscopic and histopathologic features of superficial colorectal lesions diagnosed and treated in a singlecenter and subjected to endoscopic mucosal resection (EMR). METHODS: Single-center,

retrospective, cross-sectional, observational study involving 804 mucosectomies conducted at our institution from November 2000 to June 2015. EMR indications included Paris subtypes 0-Is and 0-II lesions and laterally spreading tumors (LST). Recurrent lesions previously treated were excluded. Statistical analyses were performed using qui-square test.

RESULTS: 483 lesions were in female subjects (60.1%), with a mean age of 63. The most frequent EMR indication was LST-G (331 patients; 41%). Paris 0-IIc lesions represented 10.7% of the indications (86 cases). Related to size, 263 lesions (32.7%) had up to 10 mm and 62 lesions (7.7%) had more than 50 mm. Bleeding was reported in 104 procedures (12.9%) and we had 2 perforations (0.25%). En bloc resection was possible in 458 cases (57%). Follow-up was obtained in 364 subjects (45.3%), with a recurrence rate of 26.6% (97 lesions), more frequently in the LST-G cases (76% vs 0–20%), piecemeal EMR (46% vs 6%), size >40 mm (72%), rectal location (51%) and bleeding during the procedure (39% vs 25%). Statistical significance (P < 0.01) was found comparing location and lesion subtype (33% LST-NG located in the right colon; 46% LST-G located in the left colon), location and en bloc resection (52% in the right colon) and location and recurrence (21% right colon vs 35% left colon). We had no mortality in this study.

CONCLUSIONS: EMR is a safe endoscopic resection technique, with low complication and recurrence rates and no mortality in this study. Recurrence was associated to large lesions, LST-G subtype cases, piecemeal EMR technique, rectal location and bleeding during the procedure. Conflict of Interest: None declared.

1 Westmead Hospital, Sydney University, Sydney, 2Princess Alexandra Hospital, Brisbane, and 3Western Hospital, Melbourne, Australia

AIMS: EMR of LSL ≥20 mm is commonly performed in a single session (ssEMR). In cases where the lesion cannot be completely resected on the first attempt, there may be benefit from a repeat attempt (tsEMR). METHODS: This study aimed to evaluate the efficacy and safety of tsEMR. Amongst a prospective study of patients referred for EMR, incompletely resected LSL were referred for surgery or tsEMR. At tsEMR all visible residual tissue was removed by snare if possible. Thereafter thermal treatment was permitted. Surveillance colonoscopy was performed at 5 months (SC1) and 18 months (SC2). The primary outcome was avoidance of surgery.

RESULTS: 1944 lesions underwent EMR. 127 lesions could not be completely resected. 43 lesions underwent tsEMR with success in 36 (83.7%). Compared to ssEMR, tsEMR lesions were larger (median size 50 mm vs 30 mm, P < 0.001), more often tubular adenomas (P = 0.037) and exhibited more submucosal fibrosis (P < 0.001). Reasons for requiring tsEMR included poor endoscopic access (39.5%), particularly at the ileocaecal valve (ICV) and nonlifting of the LSL (37.2%). Failure of tsEMR was predicted by greater size of LSL (50 mm in the failed group vs 40 mm in the successful group, P = 0.032). 2/7 lesions referred for surgery involved the ICV and 4/7 exhibited high grade dysplasia. Safety was comparable to ssEMR. Surgical referral prior to SC1 was more common in the tsEMR group (16.3% vs 5.4%, P = 0.009). Of the 36/43 (83.7%) lesions that were resected successfully, residual or recurrent adenoma (RRA) was recorded in 13/33 (39.4%) at SC1 with 2/13 (15.4%) referred for surgery and 2/12 (16.7%) to median 40.1 months follow up. CONCLUSIONS: tsEMR is a safe and surgery sparing technique in 80% of lesions where complete endoscopic resection is achieved. It shows promise as a salvage therapy where other options such as surgery are not preferred or not possible. Conflict of Interest: None declared.


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P326V: THE EXTENT OF MODERN EMR ENDOSCOPIC MUCOSAL RESECTION (EMR) OF A 90% CIRCUMFERENTIAL, LARGE LATERALLY SPREADING LESION (LSL) IN THE COLON David James Tate1, Lobke Desomer2, Mayenaaz Sidhu2, Halim Awadie2, Steven Heitman2, Michael John Bourke1 1

Westmead Hospital, Sydney University, Gastroenterology and Hepatology, Westmead, Australia and 2Westmead Hospital, Gastroenterology and Hepatology, Westmead, Australia

AIMS: Wide-field EMR is now an accepted treatment of large (20 mm or greater) laterally spreading lesions (LSL) in the colon and avoids surgery in over 90% of patients. Even circumferential LSL can be managed endoscopically with a low risk profile and cost as compared to surgery. The technique to remove this type of lesion by piecemeal EMR using a safe and systematic approach is shown in this video. METHODS: Lesion assessment using high definition white light and narrow band imaging to exclude submucosal invasion is the initial step. This is followed by a standard inject-andresect technique, using a dye-adrenalin-plasma expander solution and a variety of snares. Intraprocedural bleeding is treated with snare tip soft coagulation (STSC) (ERBE, effect 4, 80 Watts). At the end of the procedure careful inspection of the post EMR defect (PED) is performed to exclude deep mural injury (DMI) and residual adenomatous tissue.

RESULTS: A 10 cm, 90% circumferential, Kudo pit pattern type IV, Paris 0-IIa+Is rectal LSL is removed by piecemeal EMR. Minor intraprocedural oozing within the defect is treated with STSC. Careful inspection of the PED reveals no evidence of DMI or residual adenoma. The patient was discharged on the day of the procedure and kept on clear fluids overnight. There was no delayed bleeding of perforation. CONCLUSIONS: Wide-field EMR of circumferential colonic LSL is suitable and safe in experienced centres. Even for very extensive, almost circumferential LSL it should be considered as the first line treatment over surgery given its safety profile. Careful follow-up 4–6 months after the EMR procedure is necessary to exclude recurrence. Conflict of Interest: None declared.

P327: ENDOSCOPIC MANAGEMENT OF LARGE RECTAL POLYPS Hubert Nietsch St. Elisabeth Medical Center, Division of Gastroenterology, Halle, Germany

AIMS: Since the advent of screening colonoscopy we diagnose a lot more of large (>5 cm) asymptomatic rectal polyps. With the introduction of EMR (endoscopic mucosal resection)

and ESD (endoscopic submucosal dissection) the endoscopist has now endoscopic means to resect these lesions effectively.

METHODS: Piecemeal EMR after saline lifting, en-bloc resection using ESD or hybrid resection methods (circumferential incision followed by snare resection) were used.

RESULTS: We report on the successful complete endoscopic resection of large rectal adenomas, all measuring >5 cm in diameter (size 5.5–11 cm), in 62 consecutive patients (age 45– 84 years). All lesions could be excised completely. 23 adenomas were resected en bloc and the remainder in piecemeal fashion. Given the rich arterial blood supply of the rectum, bleeding was the most commonly observed complication. Haemostasis during the resection was accomplished by thermal means (snare tip coagulation, haemograsper). Haemostatic clips were only used at the end of resection. In the event of delayed postpolypectomy bleeding all standard haemostatic techniques were used including haemostatic sprays. One patient had a T1 carcinoma with submucosal invasion >1000 μm and subsequently underwent surgical resection 4 weeks after the endoscopy. The resection specimen did not show any residual tumor or lymph node invasion. All patients underwent a followup endoscopy 6 months after the initial resection: 5 patients (9%) had a recurrence (average size 11 mm) which could be completely resected endoscopically without any further recurrence. Of note all recurrent adenomas were seen in patients who underwent initial piecemeal resection. CONCLUSIONS: The novel endoscopic resection methods enable us to remove even large circumferentially spreading rectal adenomas safely. To assure complete resection thorough histological examination and rigorous endoscopic follow-up are of paramount importance. En bloc ESD seems to have a lower recurrence rate compared to piecemeal EMR. Conflict of Interest: None declared.

P328: CHARACTERISATION OF SERRATED ADENOMAS/POLYPS (SSA/P) WITH IMAGE ENHANCEMENT USING OE Sneha John1,2, Dianne Jones1 Logan Hospital, Gastroenterology, Logan, and 2Gold Coast University Hospital, Gastroenterology, Southport, Australia

1

AIMS: Optical biopsy using image enhanced endoscopy has been shown to be accurate in differentiating adenomas from hyperplastic polyps. Serrated adenomas/ polyps are harder to detect and characterise, particularly in the proximal colon. These lesions are the precursors of almost a third of colo-rectal cancer. The utility of image enhancement in diagnosing SSA/Ps is not fully established. OE is a new image enhancement technology which combines the analysis of microvascular pattern with band limited light and digital chromoendoscopy. The combination of enhanced vascular and mucosal pit pattern is expected to improve detection and characterisation of


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 colonic polyps including SSA/Ps. The aim of our study was to assess the accuracy of OE in diagnosing and characterising SSA/ Ps.

METHODS: Data was collected prospectively over an 8 month period by a single expert endoscopist using high definition white light and OE for image enhancement. All polyps detected were characterised using OE1 and 2 modes. Endoscopic prediction of SSA/Ps was matched against histopathology to determine diagnostic accuracy.

RESULTS: 43 polyps were predicted to be SSA/Ps with OE during the study period.29 of these polyps were less than 10 mm in size. 33 polyps (76%) were in the proximal colon and a third of these were greater than 10 mm in size. 40 were confirmed to be serrated adenomas by a pathologist. 2 polyps erroneously predicted were hyperplastic on pathology and the other lesion was a tubular adenoma. All 3 of these were less than 10 mm in size. Positive Predictive value for SSA/Ps in our study is 93%. CONCLUSIONS: Our early experience using OE for the characterisation of SSA/Ps suggests a high sensitivity and positive predictive value. However, challenges remain in accurately predicting diminutive polyps and in differentiating them from hyperplastic polyps. Further prospective studies using validated criteria for SSA/Ps with image enhancement is required. Conflict of Interest: None declared.

P329: CLINICAL SIGNIFICANCE OF SOLITARY LARGE SESSILE SERRATED ADENOMAS (SSA) Lobke Desomer1, David James Tate2, Mahesh Jayanna1, Nicholas Burgess2, Halim Awadie1, Duncan McLeod1, Michael John Bourke2 Westmead Hospital, Westmead, Australia, 2Westmead Hospital, Sydney University, Westmead, Australia

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In the S-SSA group lesion size was significantly smaller (25 vs 30 mm, P = 0.023), showed more submucosal fibrosis (23.3% vs 5.3%, P = 0.008) and was more frequently located proximal to the transverse colon (79.1% vs 57.9%, P = 0.026) as compared to the SPS group. Patients with SPS had more conventional (14% vs 0%, P = 0.010) and high-risk adenomas (29.8% vs 9.3%, P = 0.014) than the S-SSA group. The presence of dysplasia was similar in both groups (21% in the SPS group and 17% in the S-SSA group). No differences were noted between the group with SPS and the 2–4 SSA group. In only 5/57 (10.9%) of cases, SPS was recognized by the referrer.

CONCLUSIONS: S-SSA have a different colonic distribution and a lower polyp burden as compared to SPS. High rates of dysplasia were noted in all groups warranting adequate surveillance. SPS is only in the minority of cases recognised by the referring physician. This is however of paramount importance since SSAs with dysplasia are thought to be largely responsible for proximal interval cancers. Conflict of Interest: None declared.

P330: PILOT STUDY ASSESSING THE UTILITY OF THE JAPANESE NBI EXPERT TEAM (JNET) CLASSIFICATION OF COLORECTAL POLYPS Amit Yelsangikar, Pradeep Kakkadasam Ramaswamy, Kayalvizhi Nagarajan, N. K. Anupama, Naresh Bhat Aster CMI Hospital, Department of Gastroenterology, Liver Diseases and Clinical Nutrition, Bangalore, India

AIMS: Many studies have reported on the use of narrow band imaging (NBI) colonoscopy to differentiate neoplastic from nonneoplastic colorectal polyps. The aim of this study was to assess the utility of the NBI based JNET Classification in accurately diagnosing colorectal polyps. METHODS: All procedures were carried out with a prototype

AIMS: Although up to 30% of colorectal carcinomas develop via the serrated pathway, the natural history and malignant potential of solitary large (≥20 mm) SSA (S-SSA) is incompletely understood.

METHODS: Data was collected prospectively from a tertiary referral center, from the diagnostic procedure performed by the referring endoscopist, EMR procedure and first surveillance colonoscopy in patients with ≥1 large SSA. Patients were categorised in 3 groups: S-SSA, serrated polyposis syndrome (SPS) and ≥1 SSA without fulfilling the criteria of SPS. The SPS group was compared to the S-SSA and 2–4 SSAs group.

RESULTS: 151/1027 (14.7%) lesions removed by EMR were SSAs ≥20 mm. 30/151 (19.9%) were excluded as they could not be assessed for polyp burden. 57/121 (47.1%) of patients had SPS, 43/121 (35.5%) had 1 large SSA and 21/121 (17.4%) belonged in the 2–4 SSA group.

190 series Exera III NBI system with Dual Focus capability. Histology of each polyp was predicted in real time with NBI-DF based on the JNET classification.

RESULTS: 30 polyps were analyzed in 17 patients. Mean polyp size was 7.3 mm. 11 were diminutive, 15 were small (6–9 mm) and 4 large (>10 mm). The final histopathological diagnosis showed 8 polyps to be hyperplastic, 22 adenomatous (3 SSA, 13 tubular, 5 villous adenoma). The sensitivity, specificity, PPV, NPV of the JNET classification was 100%, 12.5%, 75.8% and 100% respectively. CONCLUSIONS: In this preliminary feasibility study, NBI accurately predicted the histology of colorectal polyps. Conflict of Interest: None declared.


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COLON AND RECTUM: ENDOSCOPY: HEMORRHOIDS/ANAL DISORDERS P331: USE OF FLEXIBLE ENDOSCOPIC RUBBER BAND LIGATION FOR TREATMENT OF SYMTOMATIC INTERNAL HEMORRHOID (GRADE 1, 2, 3) USING FORWARD (NON- RETROFLEXION) METHOD Sarkawt Raof1, Mohamed Alshekhani2 1

Sulaimani Shar Hospital, and 2Sulaimani University, Medicine, AS Sulaimaniyah, Iraq

AIMS: To evaluate the role of flexible endoscopic band ligation in the treatment of symptomatic internal hemorrhoids using forward viewing approach. METHODS: A prospective cohort study was performed in Endoscopy unit of Kurdistan center for gastronetrology&hepatology&Shar hospital and private clinic. One hundred patients with symptomatic internal piles were evaluated. All patients were managed by flexible endoscopic band ligation using the forward or antegrade viewing approach. The patients were followed up by for 6 months. Statistical Package for Social Sciences (SPSS) version 21 was used for data analysis.

RESULTS: Mean age of hemorrhoid patients was 32 9 years, 39% of them were in 30–39 years age group. Male to female ratio as 2.7:1. The common presenting symptom of hemorrhoid patients was bleeding per rectum (BPR) (55%); followed by feeling of anal protrusion (48%). About half of studied patients (45%) had second degree internal hemorrhoid, 38% of patients had third degree and 17% of them had first degree internal hemorrhoid. Mild anal pain represented 77.1% of postoperative complications. Six month postoperatively, 69% of studied patient’s perceived cure, 20% improved, 8% unchanged and 3% perceived worsening. A significant decline in third degree was observed after RBL for hemorrhoid patients (P = 0.04). CONCLUSIONS: Rubber band ligation is good and safe nonsurgical technique for management of internal hemorrhoids with high degree of patient´s satisfaction. Conflict of Interest: None declared.

P332: ENDOSCOPIC MANAGEMENT OF INTERNAL PILES: A PROSPECTIVE COMPARATIVE STUDY BETWEEN ENDOSCOPIC INJECTION SCLEROTHERAPY AND ENDOSCOPIC BAND LIGATION Ahmed Gamal Darwish Cairo, Giza, Egypt

AIMS: Hemorrhoids are a common complaint with estimates suggesting a prevalence of 4% of the adult population.

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 Treatments such as rubber band ligation (RBL), sclerotherapy and excisional surgery have been in use for many years, and recently stapled hemorrhoidopexy, has gained acceptance[1].

OBJECTIVES: To assess the efficacy and safety of retroflexed endoscopic hemorrhoidal therapy comparing the two most popular methods of endoscopic hemorrhoidal treatment, namely rubber band ligation (RBL) and injection sclerotherapy with Ethanolamine Oleate (EAO) in cases with bleeding/rectum due to internal piles. METHODS: This was a prospective, randomized comparative study that included 180 patients who presented to the gastroenterology unit with bleeding/rectum and was attributed to internal hemorrhoids.

RESULTS: The study included 180 patients; 76 females and 104 males, with a mean age of 45.4 ears (range 26–76 ears). Sigmoidoscopy showed that 88 patients had GIII and 92 had GII internal hemorrhoids. CONCLUSIONS: Our opinion the use of these 2 techniques BL & IS using a videoscope in the retroflexed position allows extreme control regarding the site of treatment application with better visibility and maneuverability that will completely change the previously reported incidences of complication when using older techniques especially the anoscopic approach which sometimes even requires anal dilatation. Conflict of Interest: None declared.

COLON AND RECTUM: ENDOSCOPY: INFLAMMATORY BOWEL DISEASE P333: CLINICAL SIGNIFICANCE OF ENDOSCOPIC MUCOSAL HEALING IN PATIENTS WITH ULCERATIVE COLITIS Byung Ik Jang, Moon Joo Hwang, Kook Hyun Kim, Kyeong Ok Kim, Tae Nyeun Kim Yeungnam University College of Medicine, Daegu, Korea

AIMS: The aim of the presents study was to evaluate the clinical significance of mucosal healing (MH) in patients with ulcerative colitis (UC). METHODS: The medical records of consecutive 135 patients with UC who were followed up for more than 6 months and underwent at least twice or more colonoscopies (CFS) during follow-up duration was reviewed retrospectively. Endoscopic MH was defined as Mayo endoscopic score 0 or 1. Disease flare up was defined as new prescription of steroid, medication change or admission related to the disease.

RESULTS: Among 135 patients, 68 patients (50.4%) showed MH at colonoscopy during follow up period. The rate of steroid usage before CFS was significantly higher in non-MH group. Mean follow up duration after CFS was 22.63 21.6 months and flare up was noted in 9 cases (13.2%) of MH group and 42 cases (62.7%) of non-


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 MH group. Median interval from colonoscopy to flare up was 9.6 15.5 momths in MH and 7.8 12.8 month in non-MH group (P = 0.876). The steroid usage (P = 0.001), medication change for symptom control (P = 0.001), admission rate ofpatients (P = 0.001), WBC count, ESR and CRP after CFS were significantly higher in non-MH group. There were two cases of total colectomy during follow-up and all of them were in nonMH group. In patients with flare up, disease duration before CFS was significantly shorter (P = 0.018) and WBC count (0.001) and CRP level (0.001) was significantly higher. Factors associated with disease flare up were no achievement of MH (P = 0.001).

CONCLUSIONS: Patients with endoscopic MH in UC showed less frequent steroid use, medication change for symptom control and admission. They showed better disease course than those without MH. Because MH is associated with disease flare up, we need to treat more actively with the goal of endoscopic MH for better long term outcome. Conflict of Interest: None declared.

P334: CROHN´S DISEASE Susanto Hendra Kusuma Hasanuddin University, Internal Medicine, Makassar, Indonesia

AIMS: Crohn´s disease is a chronic transmural inflammatory disease of the gastrointestinal tract with an unknown etiology. Crohn´s disease can involve any part of the gastrointestinal tract from the mouth to the anus but most commonly affects the small intestine and colon. Currently, the diagnosis of Crohn´ s disease include clinical aspects, radiological, endoscopic, pathologic, and examination of faeces specimens.

METHODS: We reported a male patient aged 22 years old with chief complain hematochezia since 4 years. The other symptoms is diarrhea 5–7 times daily and painfull in whole abdomen. There is decreasing of weight about 20 kgs in last 4 years. From BNO and Colon in Loop ulcerative colitis with microcolon in descenden and transversum colon with rectosigmoid diverticulosis. From colonoscopy result is ulcerative and oedema mucosal with mucopurulent secret from caecum until rectum and pseudopolyp in some segmen of colon. The biopsy from colonoscopy result is infiltrative lymphosit. The patient followed up from January 2014 until July 2015, in Wahidin Sudirohusodo Hospital, Hasanuddin University, Makassar, South Sulawesi, Indonesia.

RESULTS: It has been reported a case report male, 22 years old, with Crohn´s disease. The diagnosis is based on patient history, physical examination, BNO examination with (out) contrast, colonoscopy examination and biopsy examination. The gold standart examination for adjusted the diagnose are endoscopy (colonoscopy) and biopsy.


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usually are hematochezia, diarrhea and weight decrease. It has been reported a male patient aged 32 years old diagnosed based on endoscopy (colonoscopy) and biopsy. Conflict of Interest: None declared.

P335: STUDY OF CORRELATION OF SUSTAINED CLINICAL REMISSION WITH ENDOSCOPIC HEALING IN ULCERATIVE COLITIS Deepakkumar Gupta, Shobna Bhatia, Akash Shukla, Sangeet Saurav, Abhinav Jain, Nivedita Seth GS Medical College and KEM Hospital, Gastroenterology, Mumbai, India

AIMS: Endoscopic healing (EH) is an important goal in management of ulcerative colitis (UC), as it can predict sustained clinical remission and lesser need of surgery. With the advent of biological agents, histological mucosal healing is now the ultimate goal of therapy. We evaluated the predictors of endoscopic and mucosal healing, and their relation to clinical disease during follow up. METHODS: Patients with recently diagnosed UC or with acute flare were enrolled. Patients were treated with step-up therapy. After they achieved clinical remission, they were assessed every 3 months for clinical remission (cessation of bleeding and normal stool frequency), EH (Mayo score of 77 years. Salient indications for colonoscopy were: lower gastrointestinal bleeding in 129 (59.4%) patients, lower abdominal pain in 55 (25.3%) patients, altered bowel habit in 21 (9.7%) patients, chronic diarrhea in 20 (9.2%) patients, iron deficiency anemia in 6 (2.8%) patients and mass lesion in 4 (1.8%) patients while surveillance colonoscopy was the indication in 3 (1.4%) patients. The diagnostic yield of colonoscopy was highest when the indication was lower gastrointestinal bleeding (93.0%), followed by mass lesion (75.0%), chronic diarrhea (70.0%), surveillance in special group of patients (66.7%), iron deficiency anemia (66.4%), lower abdominal pain (41.8%) while the yield was lowest when the indication was altered bowel habit (constipation)(38.1%). The colonoscopy procedure was completed in 207 (95.4%) patients. Supervised trainee performed colonoscopy for 22 (10.1%) of the study population. Complications after colonoscopy were colonic perforation in 1 (0.46%) patient and abdominal distension in 1 (0.46%) patient.

surveillance colonoscopy, the yield of colonoscopy was highest when it was performed to investigate lower gastrointestinal bleeding (93.0%). Conflict of Interest: None declared.

P346V: USING TWO ENDO-LOOPS TO SECURE THE APPENDICULAR STUMP DURING COLONOSCOPIC REMOVAL OF AN INVERTED APPENDIX: A CASE REPORT WITH VIDEO Panida Piyachaturawat1, Rapat Pittayanon1, Rungsun Rerknimitr1, Tanyaporn Chantarojanasiri2 1

Chulalongkorn University and King Chulalongkorn Memorial Hospital, Division of Gastroenterology, Faculty of Medicine, and 2Police General Hospital, Department of Internal Medicine, Bangkok, Thailand

AIMS: An inverted appendix is an uncommon condition that rarely detected during colonoscopy. There has been a limited number of case report of inverted appendix and its management. METHODS: We reported a case of inverted appendix undergoing colonoscopic appendectomy by using two endo-loops to secure the appendiceal stump.

RESULTS: A 54-year-old woman had a history of lower abdominal pain without fever. She was investigated by colonoscopy. There was a 3-cm polypoid lesion overlying with normal colonic mucosa originated from the appendiceal orifice which was compatible with an inverted appendix. After a careful consideration, colonoscopic appendectomy was performed. The first endoloop was placed around the base of the appendix. The appendix was cut just above the loop, using a polypectomy snare. Second endoloop was applied to secure the appendicular stump (as showed in the video). A histopathology confirmed as mild acute appendicitis. No immediate or delayed complications occurred. CONCLUSIONS: In an inverted appendix, because of its uncommon presentation, the data about etiology, management, and its prognosis are not well established. Some case reports showed endometriosis as a cause of an inverted appendix. Hypothetically, colonic mucosal biopsy is insufficient to diagnose inflammation at the serosal side of inverted appendicitis. Some experts recommended for an endoscopic removal of inverted appendix to get more accurate histopathology. Currently, there has been no report on the complications of inverted appendix removed by a colonoscopy, however, a risk of delayed stump leakage is always a concern. Conflict of Interest: None declared.

CONCLUSIONS: Indications for colonoscopy were gastrointestinal bleeding, lower abdominal pain, altered bowel habit, chronic diarrhoea, iron deficiency anemia, mass lesions and



P347V: ENDOSCOPIC TRASLUMINAL DRAINAGE OF DIVERTICULAR ABSCESS. A CASE REPORT Hector Julian Canaval Zuleta, Guillermo Cacho Acosta, ndez Rodrıguez Conrado Ferna Hospital de Alcorcon, Gastroenterology and Endoscopy, Madrid, Spain

AIMS: To describe the case of a diverticular endoluminal abscess, sucessfully endoscopically drained, without any complication. METHODS: We review the case of an endoscopic drainage performed in the endoscopic unit with a follow-up during hospitalization and after two month of having been discharged.

RESULTS: A 65-year-old man who came for a colonoscopy screening due to occult blood stool and a family history of colorectal cancer. He referred a 2 week history of abdominal pain and dysthermia, without fever, nausea, vomiting or diarrhea. Colonoscopy revealed diverticulitis in the sigmoid colon and a submucosal mass of approximately 20 x30 mm. in size with a slightly hyperemic surface mucosa. Palpation of this area with cold forces was soft and after oppression it drained a whitish discharge, with thick purulent aspect with decompression of the lesion. CT scan was later performed and showed sigmoid diverticulitis associated with an endoluminal without evidence of perforation. Antibiotic therapy was given with adequate clinical response. CONCLUSIONS: The diverticular abscess in this case is an intraluminal complication of a diverticulitis but it is usually extraluminal. There are only two cases in the literature described by Barkin et al and Calzolari C et al with similar presentation. This would be the third case of a diverticular abscess succesfully endoscopically drained and without any complications. While colonoscopy is not recommended in episodes of acute diverticulitis, there are certain cases in which it has to be considered not only as a diagnostic tool but also as a minimally invasive therapeutic option. Conflict of Interest: None declared.

P348: A CASE OF COLO-ENTERIC FISTULA FROM ACCIDENTAL PLASTIC BREAD CLIP INGESTION Ravinder Ogra, Ming Han Lim, Stephen Gerred Middlemore Hospital, Gastroenterology, Auckland, New Zealand


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colitis with ulceration and focal mild crypt architectural change. CT abdomen performed 2 weeks post colonoscopy to exclude malignancy showed a foreign body (presumed surgical clip) within a wide neck, thick walled proximal sigmoid diverticulum which was inseparable from a loop of small bowel, raising the possibility of a colo-enteric fistula. A follow up CT abdomen 3 months later showed similar findings. A subsequent flexible sigmoidoscopy revealed a bread clip within a large cavity in the proximal sigmoid colon on a background of sigmoid diverticulosis. A colo-enteric fistula was confirmed upon bread clip removal and was closed endoscopically with a combination of argon plasma coagulation, glue injection and 3 resolution clips. Unfortunately, he was admitted 2 days post therapeutic endoscopy with increasing abdominal pain and vomiting. Repeat CT abdomen confirmed partial small bowel obstruction (transition point at site of glue injection), glue embolisation into the adjacent mesenteric veins and left portal vein but no evidence of persistent colo-enteric fistula. He was discharged on day 14 after improving with anticoagulation and conservative management.

CONCLUSIONS: Plastic bread clips should be removed when ingested as they can result in serious intestinal injury. Glue injection should be used with caution when managing coloenteric fistulae endoscopically. Conflict of Interest: None declared.

P349: CAP-ASSISTED ENDOSCOPIC MUCOSAL RESECTION SUITABLE FOR TREATMENT OF SMALL RECTAL NEUROENDOCRINE TUMOURS Genki Tsukuda, Noboru Yokoyama, Akiko Ueno, Kunio Asonuma, Kai Matsuo, Shuei Arima, Masayuki Isozaki, Naoyuki Uragami, Haruhiro Inoue Showa University Koto-Toyosu Hospital, Tokyo, Japan

AIMS: To investigate the advantages of various endoscopic resection methods for rectal neuroendocrine tumours (NETs). Indications of endoscopic resection for rectal NETs are less than 10 mm in the guidelines. However, which endoscopic methods are suitable for treatment of small rectal NETs are unclear. METHODS: This study aimed to evaluate the efficacy and safety of endoscopic mucosal resection using a cap (EMR-C) compared with ESD for the treatment of 3–9 mm rectal NETs.

MATERIAL AND METHODS: From March 2014 to August AIMS: We report an unusual cause of colo-enteric fistula and highlight risks associated with endoscopic management.

METHODS: This is a rare case report of unusual presentation and its endoscopic management.

RESULTS: A 72 year old Fijian Indian man who had a gastroscopy and colonoscopy to investigate mild iron deficiency anaemia and constipation. His gastroscopy showed Grade A oeosphagitis while his colonoscopy showed an area of severely inflamed sigmoid diverticulosis and a smooth sigmoid stricture which was biopsied. Histology confirmed moderately active

2016, 9 patients (15 lesions) with rectal NET were treated by EMR-C (10 lesions) or ESD (5 lesions) in our center. All cases were pathologically diagnosed as rectal NETs. The en bloc resection rate, pathological curative resection rate, procedure time, and incidence rates of complications were evaluated.

RESULTS: The mean size in 5.2 2.2 mm. The mean tumours size was no significantly between both groups (EMR-C 4.0 1.4 min, vs ESD 7.6 1.1). Of the 15 rectal NETs, 13 were histopathologically diagnosed as NET G1 and two as NET G2 in ESD group. The mean procedure time was shorter for


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EMR-C than ESD (3.7 1.6 min, vs 30.4 11.1 P < 0.01). The rates of en bloc resection and pathological curative resection rate were 100% in both groups. One case 7 mm in size, though EMR-C was attempted, it was not sucked completely in the cap for scar of previous biopsy. This lesion treated with ESD without complications. One patient in the EMR-C group experienced delayed bleeding, which was successfully treated by hemoclipping. No patients in the both groups severe complications occurred.

CONCLUSIONS: Considering the clinical efficacy, procedure time, and complication rate, EMR-C may be suitable for treatment of small rectal neuroendocrine tumours. Conflict of Interest: None declared.

P350V: AN UNUSUAL CASE OF VASCULAR MALFORMATION Sushant Sethi1,2 Apollo Hospitals, Bhubaneswar, and 2Apollo Hospitals, Gastroenterology, Bhubaneswar, India

1

AIMS: 16 year old male had lower GI bleed since childhood. Underwent surgery for remnant urachus earlier.

METHODS: We did a retrospective analysis of patients attending the outpatient services of Department of Digestive Health and Disease between January 2011 and April 2016 who had constipation as the predominant complaint without alarm signs like rectal bleeding, anemia, weight loss, family or previous history of colonic malignancy and a normal clinical examination.

RESULTS: A total of 189 patients were included in this study, of which men were 126 (68%) and women were 60 (32%). 63 % of the men were >50 years of age and 60% of women were above 50 years of age. Malignant growth was observed in four patients (2.11%). Benign polyps were seen in sixteen patients. Diverticulae mostly in the cecum was observed in nine patients. SRUS, hemorrhoids and stricture were seen in two, sixteen and one patient respectively. Normal colonoscopic finding were observed in 141 patients : 79% of age >50 years group and 72 % of age 20 mm (ACE Study, NCT 01368289). An incremental cost-effectiveness analysis was performed over an 18-month time horizon. WFEMR, universal ESD and selective ESD for lesions suspicious for submucosal invasive cancer (SMIC) (WF-EMR for remainder) were compared. Outcomes included the number of surgeries performed and incremental costs per surgeries avoided. Lowrisk SMIC (LR-SMIC) was defined by the presence of any of the following: tumour depth < 1000 microns below the muscularis


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mucosa and the absence of both lymphovascular invasion and tumour budding.

RESULTS: 1317 patients with 1375 lesions were analysed. The prevalence of SMIC and LR-SMIC was 8.3% and 3.7%, respectively. Lesion assessment for SMIC had a sensitivity and specificity of 21.1% and 98.9%, respectively. In the base case analysis selective ESD cost $5605 per case and prevented 14 surgeries per 1000 patients compared to WF-EMR ($5723 per case). 28 ESDs would be performed per 1000 patients. Universal ESD ($9076 per case) would prevent an additional 23 surgeries compared to selective ESD, at an incremental cost of $146,312 per surgery avoided. Selective ESD using Japanese criteria prevented 28 surgeries compared to WF-EMR. Over 90% of the 350 ESDs were completed on benign lesions. CONCLUSIONS: WF-EMR is an effective and safe treatment option for the majority of LSL at a slightly higher cost than selective ESD. A selective ESD strategy is most cost-effective, however, ESD is applicable to a small proportion of lesions whilst the majority are treated by WF-EMR in such a strategy. Universal ESD cannot be justified. Given the small proportion of patients benefitting from selective ESD, its widespread adoption requires careful consideration. Conflict of Interest: None declared.

P354: ANTI-TB THERAPY AS A DIAGNOSTIC TOOL FOR INTESTINAL TUBERCULOSIS Than Than Aye University of Medicine 2, Department of Gastorenterology, Yangon, Myanmar

AIMS: The diagnosis of intestinal tuberculosis remains challenging due to its diverse clinical manifestations, similarities to inflammatory bowel disease, limited accuracy of diagnostic tests and restricted resources in developing countries. Staining for acid fast bacilli is only positive in less than 3% of cases and epitheloid granulomas were still need to differentiate with Chrohn’s disease. Our aim was to detect whether anti-TB trial could be used as a diagnostic tool for intestinal tuberculosis. METHODS: Patients with colonic lesions suspicious of TB (1/ 2014 - 12/2015) were collected. Demographic, presenting features, colonoscopic and histological findings were noted. Anti-TB treatment was started and follow-up colonoscopy was performed at 2-month after starting anti-TB.

RESULTS: Fifty patients were enrolled (mean age 36.96 + 17.51 years, male 44%, female 56%). Presenting symptoms were bleeding per rectum 24%, diarrhea 20%, abdominal mass 20%, pain 12%, anemia 8%, ascites 8%, intestinal obstruction 6% and constipation 2%. Seventy percent of the lesions were ulcerative, 22% ulcerohypertrophic and 8% hypertrophic. They were seen at terminal ileum 14%, ileocaecal valve 32%, caecum 12%, ascending colon 12%, rectum 4%, as skipped lesions at right colon 16% & left colon 10%. Only 6 cases (12%) had caseating granulomas and 44 cases (88%) turn out to be


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non-specific colitis. Anti-TB trial was given to those lesions with negative biopsy. Follow up colonoscopy was done at 2-month after. Twenty patients (45.5%) did follow up colonoscopy. Among them, 80% of the lesions (ulcerative 81% & hypertrophic 19%) healed completely and 20% of them resolved significantly although it was not statistically significant (P = 0.456).

P356: TRANSEANAL MINIMALLY INVASIVE SURGERY (TAMIS) FOR RECTAL LESIONS

CONCLUSIONS: In this preliminary report, majority of the

Showa University Ko-To Toyosu Hospital, Digestive Disease Center, Tokyo, Japan

lesions healed completely with anti-TB treatment. High dropout rate is the weakness of the study. However, anti-TB trial is still indicated in the area with high prevalence of tuberculosis and limited diagnostic modality. Further study with larger sample size is needed. Conflict of Interest: None declared.

Noboru Yokoyama, Akiko Ueno, Masayuki Isozaki, Genki Tsukuda, Kunio Asonuma, Kai Matsuo, Syuei Arima, Naoyuki Uragami, Haruhiro Inoue

P355: ENDOSCOPIC MANAGEMENT FOR COLON NEUROENDOCRINE TUMORS 15 years). The most common indications for colonoscopy were intermittent lower gastrointestinal bleed in 60% cases followed by chronic diarrhea in 40% cases, intermittent lower abdominal cramping pain and loose motions in 30% cases, intermittent constipation in 20% cases and painful defecation in 15% cases. Out of 2027 cases 44.21 (896)% cases had normal colonoscopy findings, 12.25 (248)% cases had internal hemorrhoids, 9.6%(194)% cases had rectal growth, 6.8 (138)% cases had colonic growth, 6.6 (134)% cases had ulcerative colitis, 5.8 (118)% cases had anal fissure, 4.27 (86)% cases had infective colitis, 3.58 (72)% cases had rectal polyps, 2.72 (55)% cases had ulcerative proctitis, 2.32 (47)% cases had colonic polyps and 1.85 (37)% cases had crohns disease.

RESULTS: Depression was found in 105 patients (60 females,

P360: ASSESSMENT OF ETIOLOGIES AND CLINICAL PRESENTATION IN PATIENTS SUFFERING FROM LOWER GASTROINTESTINAL (LGI) BLEEDING IN TERTIARY CARE CENTRES OF EASTERN ODISHA Kaibalya Ranjan Dash, Sivaram Prasad Singh, Chitta Ranjan Panda, Prasanta Parida, Suryakanta Parida, Sambit Kumar Behera, Preetam Nath, Girish Kumar Pati, Jimmy Narayan, Pradeep Kumar Padhi, Ayaskant Singh SCB Medical College, Gastroenterology, Cuttack, India

AIMS: To assess different etiologies and clinical presentation in patients suffering from lower gastrointestinal (LGI) bleeding in tertiary care centres of Eastern Odisha. METHODS: Consecutive patients suffering from LGI bleed attending the gastroenterology department of S.C.B. Medical College & Hospital, Sum hospital and college from January 2016 to August 2016 were enrolled in the study. Consecutive patients


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with visible hematochezia of age >18 years were included in this study while patients with suspected UGI bleed and coagulopathy were excluded.

RESULTS: Out of 159 patients 117 (73.5%) cases were males and 42 (26.5%) cases were females. Mean age of patients were 40.91 17.65 years. About 99 (62.2%) belongs to middle socioeconomic status and 60 (37.8%) of low socioeconomic status. All patient presented with bleeding per rectum, also had anorexia (54.7%), fatigue (73.5%), constipation (43.3%), tenesmus (42.2%), pain abdomen (40%). About 71.6% attended hospital after 72 h, 7.5% in less than 12 h, 5.6% between 12–24 h, 3.7% between 24–48 h, 9.45% between 48–72 h. Out of 159 cases, 12 (7.5%) had normal colonoscopy findings, 45 (28.%) cases had haemorrhoids, 9 (5.6%) cases had rectal growth, 15 (9.4%) cases had colonic growth, 30 (18.8%) cases had ulcerative colitis, 9 (5.6%) cases had anal fissure, 9 (5.6%) cases had infective colitis, 24 (15%) cases had colonic polyps, rectal varices 6 (3.7%), SRUS 3 (1.8%). CONCLUSIONS: In our study we found that most patients were male and belongs to middle socioeconomic status. Haemorrhoid is most common cause of bleeding per rectum followed by ulcerative colitis and carcinoma of colon. Conflict of Interest: None declared.

P361: RETROSPECTIVE ANALYSIS OF DIAGNOSTIC YIELD OF COLONOSCOPY IN PATIENTS WITH CHRONIC FUNCTIONAL BOWEL SYMPTOMS Anurag Tiwari1, Deepika Chaturvedi2, Ajay Nandmer1, Vinod Dixit1 1 Institute of Medical Sciences Banaras Hindu University, Gastroenterology, and 2Institute of Medical Sciences Banaras Hindu University, Biochemistry, Varanasi, India

AIMS: Functional disorders of the bowel are common and have significant impact on patients’ daily lives. Up to 50% of patients who have these symptoms undergo some form of colon examination during the course of diagnostic evaluation to look for alternative causes of their symptoms. This study is intended to evaluate spectrum of positive findings during colonoscopy and various clinical predictors of these findings. METHODS: Data was collected retrospectively from endoscopy unit of department of gastroenterology in a tertiary care hospital in north India. Patients age 18 years or more who had chronic bowel symptoms, no history suggestive of organic disease, normal physical examination and whenever indicated clinically, a normal stool examination and a normal per abdominal ultrasonography scan were included in study. Patients with blood in stool, weight loss, nocturnal symptoms and fever were excluded.

RESULTS: This study included 327 patients with male to female ratio of 70:30. Rate of ileal intubation was 93.3%. Of 327 patients 91 (27.8%) had abnormal findings during colonoscopy and these included colonic and/or ileal ulcers, ileal nodules,

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 proctitis/proctocolitis, polyps/polypoidal lesions, ulcerproliferative lesions and melanosis coli. Males and females had almost similar rate of abnormal colonoscopy. Rates of abnormal colonoscopy were 48.3, 15 and 20.4% in age groups ‘upto 30’, ‘31–50’ and >50 years; 41.3, 39.8, 24.6 and 9.6% in who had duration of symptoms for < 6, 6–12, 12–36 and >36 months; 29.5, 22.5, 30 and 26.4% in patients who had diarrhea, constipation, mixed diarrhea and constipation and abdominal pain as predominant symptoms respectively.

CONCLUSIONS: Almost 1/4th patients with functional bowel symptoms have abnormal colonoscopy findings. Predictors of these abnormal findings may be younger age and shorter duration of symptoms. Conflict of Interest: None declared.

P362: P53 IMMUNOEXPRESSION IN HIGH DEGREE DYSPLASIA COLON ADENOMAS FROM CHOLECYSTECTOMIZED CUBAN PATIENTS AND WITH CHOLELITHIASIS ~ol Jime nez Felipe Neri Pin National Center Minimal Access Surgery, La Habana, Cuba

AIMS: The progression of adenoma to adenocarcinoma is a result of inherited or acquired genetic factors present in intestinal cells. The aim of this research was to determine p53 immunoexpression in high degree dysplasia colon adenomas from Cuban patients who had been cholecystectomized and with cholelithiasis. METHODS: A cross-sectional descriptive study was performed at the Institute of Gastroenterology from May 2013 to May 2015 in sixteen adult patients with a history of cholecystectomy and with cholelithiasis, with colonoscopic polyp and histological high degree dysplasia adenoma diagnosis. Descriptive statistical, Chi-squared and Fisher´s Exact Probability tests were performed.

RESULTS: In both groups p53 immunoexpression was present in 62, 5% of patients with high degree dysplasia adenomas and there was a high frequency (75, 0%) of fecal occult blood positivity. The combined analysis of occult blood and p53 immunoexpression in both groups showed that these patients have a high positivity frequency in both tests regardless of when they were cholecystectomized and of the number of stones. CONCLUSIONS: The results of this study performed for the first time in Cuban cholecystectomized patients and with cholelithiasis shows p53 immunoexpression predisposition in high degree dysplasia colon adenomas indicating that both groups may be at risk and deserve a broader investigation.

KEYWORDS: Adenoma; high degree dysplasia; p53; cholecystectomy; cholelithiasis. Conflict of Interest: None declared.




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ENDOSCOPIC ULTRASOUND: ENDOSCOPY: EUS DIAGNOSTIC, GI TRACT

P364: OUR EXPERIENCE IN DIAGNOSTIC EUS IN ESOPHAGEAL AND GASTRIC LESIONS

P363: CONDOM METHOD ENDOSCOPIC ULTRASONOGRAPHY IS SAFE AND EFFECTIVE DIAGNOSTIC TOOL FOR ESOPHAGEAL MASS LESIONS

Chitra Shanmugam, Venkateswaran Arcot Rajeswaran, Revathy Shanmugam, Manimaran Murugesan, Malarvizhi Murugesan, M. Nagavendhan, R. Gopalakrishnan

Jeong Seop Moon, Kyung Jin Lee, Jung Hwa Min, Soo Yeon Jo, Won Jae Yoon, Soo Hyung Ryu, You Sun Kim Inje University, Internal Medicine, Seoul, Korea

AIMS: Endoscopic ultrasonography (EUS) is widely used to evaluate gastrointestinal mass lesions. Particularly in esophageal mass lesions, EUS is the method of choice to evaluate the origin and depth of invasion of the tumor. To overcome the disadvantages such as aspiration and balloon rupture by conventional EUS method, we used condom method EUS for esophageal tumor evaluation. METHODS: We investigated retrospectively thirty four patients examined by condom method EUS using high frequency ultrasound probes after diagnosed as esophageal mass lesion including submucosal tumor by standard endoscopy between January 2007 and July 2016 in Inje University Seoul Paik Hospital. We checked the originating layer, invasion depth and size of the tumor, and events complicated by procedure. If needed, we confirmed the histopathology by biopsy.

RESULTS: Condom method EUS provided high quality images of well-defined layers of esophagus through 360 degrees. In all segments of esophagus; upper, middle, lower esophagus (n = 5, 13, 16) showed high resolution images without difference. Diagnosis were squamous cell cancer (n = 5), leiomyoma (n = 10), lipoma (n = 1), squamous intraepithelial neoplasia (n = 2), acanthosis (n = 3), inflammatory fibrinoid polyp (n = 1) and extrinsic compression (n = 1). Tumors were originated from mucosa (n = 5), muscularis mucosa (n = 14), submucosa (n = 5), mucosa invading into submucosa (n = 5), propria muscle (n = 4). Size was divided into < 5.0 mm (n = 6), 5.1– 10 mm (n = 15) and >10 mm (n = 12). No complications had occurred in all cases, such as aspiration from water filled EUS and balloon rupture from balloon EUS. CONCLUSIONS: Condom method EUS is safe image diagnos-

Government Stanley Medical College, Medical Gastroenterology, Chennai, India

AIMS: Having the privilege of being the first government institution to have EUS in Tamilnadu, we are very proud to present our data. Management of some cases depended on the findings in EUS. To classify the patients according to the findings in EUS and to decide the line of management. METHODS: This is a prospective study done from August 2015 to July 2016 in the Department of Medical Gastroenterology, Government Stanley Medical College Hospital. Patients who presented with upper GI symptoms and inconclusive ugi scopy findings were included in this study. All the cases were referred to us from other deparments and other institutions also. Evaluation was done with olympus linear echoendoscope. The findings were recorded and FNA was done whenever necessary with 22 or 19 G needle.

RESULTS: Total number of patients were 21.15 patients had findings in esophagus and remaining 6 in the stomach. Among the patients with esophageal lesions 7 were male and 8 were females whereas in stomach lesions 2 were males and 4 were females. The age ranged from 12 to 74 (mean 46.19). There were 8 patients in the age group of 51–60, 5 patients in 31–40 group, 4 patientsin 41–50 group and 1 each in 11–20, 21–30, 61–70 and 71–80 groups. Leiomyoma esophagus was the commonest lesion in our study and duplication cyst came next in the list. Two patients had subcarinal node for which FNA was done. One came as granuloma with langerhans giant cell and other one acellular smear. In stomach lymphoma stood first, next was linitis and then leiomyoma. CONCLUSIONS: Esophageal and gastric submucosal lesions pose a challenge for us to diagnose and treat it. EUS helps us to diagnose the lesion and as well as to decide whether or not to treat the patient. Conflict of Interest: None declared.

tic tool of high resolution. Simply to apply inexpensive latex condom filled with water can provide good EUS visual field and images of the esophageal mass lesions along the whole esophagus including cardia without aspiration risk. Later, by comparing other EUS tools with condom method, we can verify the effectiveness and safety more exactly. Conflict of Interest: None declared.


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P365: FRANTZ’S TUMOR: DIAGNOSIS AND MANAGEMENT OF AN UNUSUAL LOCATED PANCREATIC TUMOR. CASE REPORT AND REVIEW OF THE LITERATURE Hector Adolfo Polania Lizcano1,2,3, Christian Guzman4, Hector Jimenez4,5, Rina Luna Tavera6 1 Endotek - Neiva, Gastrointestinal Surgery, 2Universidad Surcolombiana, Gastrointestinal Surgery and Endoscopy, 3 Hospital Universitario de Neiva, Gastrointestinal Surgery and Digestive Endoscopy, 4Universidad Surcolombiana, General Surgery, 5Universidad Surcolombiana, Epidemiologist, and 6Hospital Universitario de Neiva, Pathology, Neiva, Colombia

AIMS: To describe the experience in diagnosis and surgical preservative management of the pancreas head on an unusual located pseudopapillary pancreatic tumor in a South American country. METHODS: Case report. Description of clinic characteristics, diagnostic approach and surgical management.

RESULTS: We report the case of a solid pancreas pseudopapillary tumor in a 14 year-old female patient, presenting with prolonged abdominal pain and bloating. An endoscopic ultrasonography and computed tomography scan were performed, showing a tumor at the uncinate process of the pancreas with solid and multicystic component. Laboratory test revealed normal tumor markers (alpha-fetoprotein, carcinoembryonic antigen, P-HCG, CA-19-9). The surgical treatment consisted on tumor enucleation at the pancreas head. Afterwards, the patient presented with acute pancreatitis without organic dysfunction and was medically treated. The biopsy confirmed a pancreas solid pseudo-papillary tumor with cyst component. Eventually, she was asyntomatic on discharge. CONCLUSIONS: Pancreatic tumors are extremely rare, spe-

cially in children, where the pancreas pseudo-papillary tumor corresponds to 0.2 - 2% of primary pancreatic tumors, characterized by its low malignant potential and excellent prognosis. Endoscopic ultrasonography was the key imaging tool on evaluating the lesion and it is considered the best method for diagnosis, management and surgical planning for pancreatic preservative organ surgery. Conflict of Interest: None declared.

P366: EUS GUIDED FNA OF OMENTUM FOR ASSESSMENT OF ETIOLOGY OF ASCITES Ravi Daswani, Vikas Singla, Anil Arora, Ashish Kumar, Praveen Sharma, Naresh Bansal, Mayank Gautam Sir Ganga Ram Hopsital, Gastroenterology, New Delhi, India

AIMS: To assess the role of EUS guided FNA of peritoneum as a technique for evaluation of undiagnosed ascites.

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 METHODS: Patients with ascites underwent ascited fluid evaluation. If fluid analysis was non diagnostic, and tuberculosis or malignancy was susepcted, CECT was performed. Patients with thickened omentum were subjected to EUS guided sampling. Examination was performed with linear array echoendocope, omentum was focussed from anterior wall of stomach, FNA was obtained with the help of a 22G needle, ROSE was not available, cell block was made in all cases.

RESULTS: 15 patients (9 males; 5 females) with mean age 51.5 years were included in the study. All the patients had thickened omentum on CT scan, 4 patients had underlying cirrshosis. Cytological diagnosis after omental FNA was peritoneal tuberculosis in 7 patients, metastatic carcinoma in 5 patients and 1 patients had pseudomyxoma peritonei. Sample was inadequate in 2 patients. In all the patients with cirrhosis, tuberculosis was the cause of thickened omentum. Overall the yield was high, EUS FNA was diagnostic in 86.6% of cases. All the procedures were well tolerated. CONCLUSIONS: EUS guided FNA of peritoneum is a safe and efficacious technique for diagnostic assessment of patients with ascites and thickened omentum. Conflict of Interest: None declared.

ENDOSCOPIC ULTRASOUND: ENDOSCOPY: EUS DIAGNOSTIC, OTHERS P367: ADVERSE EVENTS ASSOCIATED WITH ENDOSCOPIC ULTRASONOGRAPHY AND ENDOSCOPIC ULTRASONOGRAPHY WITH FINENEEDLE ASPIRATION (RETROSPECTIVE STUDY) Mikhail Burdyukov1, Mikhail Davydov1, Andrew Nechipai2, Ilia Yurichev1, Boris Dolgushin1, Guram Ungiadze1 1 N.N. Blokhin Russian Cancer Research Center, and 2Medical Academy of Postgraduate Education of Russian Ministry of Healthcare, Moscow, Russia

AIMS: To evaluate the complications related to EUS and EUSFNA procedures in analyzed a 10-year trend (2006–2016). METHODS: In a retrospective single-center case-series, 1241 men and 1059 women, a total of 2300 patients (median age, 58 years), undergoing diagnostic EUS were included. Among a small cohort of 581 (25.3%) patients, EUS-FNA was applied.

RESULTS: Adverse events associated with the procedure were reported in 6 (0.26% out of total EUS, n = 2300) of cases, out of them 5 cases were related to EUS-FNA (0.52% out of total EUS-FNA, n = 581). Among them 1 esophageal perforation (0.043% out of total EUS, n = 2300), 2 cases of bleeding (0.086% out of total EUS, n = 2300; 0.34% out of total EUS-FNA, n = 581), 3 cases of infectious complications (0.13% out of total EUS, n = 2300; 0.52% out of total EUS-FNA, n = 581) were reportedly revealed.


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 CONCLUSIONS: EUS and EUS-FNA have emerged is a generally safe and effective modality. However, adverse events do develop. Knowledge of potential complications secondary to EUS and EUS-FNA, their expected frequency, and their associated risk factors may help to minimize their occurrence. Conflict of Interest: None declared.

P368: PERFORMANCE OF ENDOSCOPIC ULTRASOUND BY BEGINNER ENDOSONOGRAPHER IN COMMUNITY HOSPITAL Chia-Hsien Wu, Huan-Lin Chen, I-Tsung Lin, Yuan-Kai Lee, Chun-Han Cheng, Ming-Wun Wong, Ming-Jong Bair Taitung Mackay Memorial Hospital, Division of Gastroenterology, Department of Internal Medicine, Taitung, Taiwan, China

AIMS: Evaluate whether the results of excellent referral centers can be maintained in beginner endosonographer ´s hands in community hospital. METHODS: We performed 10 EUS-FNA and 13 therapeutic EUS procedures in 20 patients (male 17, female 3; mean age 59.2 years, range 33–91) between 2014 Dec through 2016 June. These are the first 20 cases underwent FNA or therapeutic EUS procedures in our hospital. We retrospectively analysis the results of above procedures, including the accuracy for pathological diagnosis and technical, clinical success rate of interventional EUS.

RESULTS: There were 6 pancreatic tumors, 3 pancreatic cystic lesions, one intra-abdominal lymphadenopathy underwent EUSFNA. The correct pathological diagnosis rate was 80%(8/20). There were 8 pancreatic pseudocysts receiving EUS guided cystogastrostomy with plastic double-pigtail stent placement. The technical successful rate was 87.5% (7/8). The failed case, who receiving only EUS guided aspiration and failure of tract dilatation and stent insertion achieved clinical success by transpapillary pancreatic stenting and antibiotics treatment. The technical successful rate of other therapeutic EUS procedures were 50% (1/ 2) in EUS-BD, 0% (1/1) in EUS-PD, 100% in EUS-RV (1/1). In one chronic pancreatitis case with gastric outlet obstruction by duodenal intramural hematoma, EUS guided transmural drainage was performed. Though successful puncture by 22G FNA needle, I was unable to dilate the tract for stent insertion. No complications such as bleeding, GI trace perforation occurred during these procedures.


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P369: ROLE OF EUS IN DIAGNOSIS OF CBD STONE IN PATIENT WITH NEGATIVE ULTRASONOGRAPHY Than Than Aye University of Medicine 2, Department of Gastorenterology, Yangon, Myanmar

AIMS: Most of the choledocholithiasis require therapeutic intervention. It is important to have an accurate, safe, and reliable method for the definitive diagnosis of choledocholithiasis before initiating therapeutic endoscopic retrograde cholangio-pancreatography (ERCP). The aim of this study was to determine the diagnostic yield of EUS in patients with high likelihood of choledocholithiasis /cholangitis with negative ultrasonography requiring therapeutic ERCP. METHODS: Patients with suspected choledocholithiasis who underwent EUS from January 2014 to December 2015 were retrospectively reviewed. The patients were selected with strong predictors of choledocholithiasis according to the clinical predictors described by the ASGE guidelines (dilated CBD >6 mm without an identifiable cause with gall bladder in situ and serum bilirubin level 1.8–4 mg/dL) were enrolled in this study. ERCP was performed when a CBD stone was disclosed by linear EUS and ERCP finding were described. Then therapeutic intervention stone extraction with billiary balloon or Dormium basket or Mechanical lithotripter was preceded.

RESULTS: Of 40 enrolled patients, 24 patients (60%) detected CBD stones, 5 normal study, 4 cases of peri-ampullary tumor, 4 cases of distal CBD stricture and 3 cases of pancreatitis were diagnosed with linear EUS. All CBD stones cases were underwent ERCP on the next day. 92% (22 /24 cases) of CBD stones were also detected with ERCP and successfully managed and 2 cases of CBD stones (8%) found in EUS were negative in ERCP balloon sweeping. CONCLUSIONS: Linear EUS is an accurate diagnostic tool for the detection of occult CBD stones in patients with high risk for the disease and other pathology and can reduce the unnecessary use of ERCP. Conflict of Interest: None declared.

P370: DIVERTICULAR DISEASE OF THE COLON: ROUTINE COLONOSCOPY AND EUS DETECTION OF THE RUPTURED DIVERTICULUM Sergey Skridlevskiy, Alexey Moskalev, Viktor Veselov

CONCLUSIONS: When compared with the results of EUS

State Scientific Center of Coloproctology, Moscow, Russia

referral centers, our EUS-FNA accuracy and technical success rate of interventional EUS drainage procedures are inferior. However, even in the beginner endosonographer´s hands, no major complications occurred and most patients achieved clinical success. EUS-FNA and therapeutic EUS are a safe and effective diagnostic and therapeutic modality. Conflict of Interest: None declared.

AIMS: The aim of this study was to determine endoscopic approach to identification of the ruptured diverticulum in patients with Diverticular disease of the colon. METHODS: We studied 23 pts (mean age 53.3 9.6 years) operated on for the recurred, complicated Diverticular disease of the colon. Duration of the Diverticular disease of the colon


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was more than 1 year in 61% cases and less than 1 year in 39%. Histological examination of the surgical specimens, preoperative routine colonoscopy and EUS records were studied in all cases. Prognostic significance of signs evaluated on the basis of the calculation of sensitivity, specificity, positive and negative predictive values, the overall accuracy.

METHODS: One hundred and eighteen patients who underwent EUS-FNA for suspected pancreatic malignancies were consecutively enrolled. All procedures were conducted by a single echoendoscopist under the same conditions. Four adequate preparations were obtained by 22-gauge needles with 20 to-and-fro movements for each pass. The 4 preparations included 2 cytological and 2 histological specimens. The pathologic reviews of all specimens were conducted independently by a single experienced cytopathologist. Sensitivity, specificity, and accuracy of the 2 examinations were compared.

RESULTS: Histological examination of the surgical specimens revealed the ruptured diverticulum in 21 (91.3%) cases. Data analysis of the routine colonoscopy revealed the presence of pus in 14 (60.8%) cases with positive predictive value for the ruptured diverticulum –100%. While, in the absence of pus the rupture of the diverticulum is possible with a probability of 33%. In these cases were identified EUS signs of the ruptured diverticulum: the presence of interrupts the hyperechogenic layer with a small (1.0–2.0 cm) hypoechoic area in this zone. Histological examination revealed not ruptured diverticulum with thickening of the muscular layer in 2 (8.6%) cases. In these cases there were no routine colonoscopy and EUS signs of the ruptured diverticulum.

RESULTS: The enrolled patients consisted of 62 males (52.5%), with the mean age of 64.6 10.5 years. Surgery was performed in 23 (19.5%) patients. One hundred and sixteen (98.3%) lesions were classified as malignant, while 2 (1.7%) were benign. Sensitivity of cytology and histology were 87.9% and 81.9%, respectively, with no significant difference (P = 0.190). Accuracy was also not significantly different. Cytological examination was more sensitive when the size of lesion was 50%) and compared between various types of collections.

RESULTS: 50 patients (mean age–41.84 11.7 years, 44% males) of AP with PFC were analysed. A total of 61 PFC were detected, 11 were distant, demonstrable only on CT and remaining 50 were peri-pancreatic, which could be analysed using both on CT & EUS. 18 (36%) had acute necrotic collections (ANC), 29 (58%) had walled off necrosis (WON) and 3 (6%) had pseudocysts. SD was detected in 46 (92%) patients on EUS, while only 16 (32%) patients on CT (P < 0.001). On EUS, SD noted was minimal in 11 (22%), moderate in 23 (46%) and profound in 16 (32%). 72% of ANC’s labelled on CT had profound SD and 30% of pseudocysts labelled on CT had moderate SD, all of whom were managed conservatively. Amongst WON’s labelled on CT, 8 (27.5%) had minimal SD who could be

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 managed conservatively; 18 (62%) had moderate SD, 7 (38%) of whom required intervention and 3 (10.3%) had profound SD, all (100%) of whom required intervention (P < 0.001).

CONCLUSIONS: EUS is better modality than CT to detect solid debris in PFC. EUS quantification of solid debris can be used as a guide for selecting the treatment modality. Conflict of Interest: None declared.

P376: OUR EXPERIENCE WITH EUS IN PANCREATIC LESIONS Manimaran Murugesan, Murali Ramamoorthy, Venkateswaran Arcot Rajeswaran, Revathy Shanmugam, Chitra Shanmugam, Deven S. Gosavi, M. Nagavendhan Government Stanley Medical College, Medical Gastroenterology, Chennai, India

AIMS: We see maximum number of patients with pancreatic problems nowadays. Sometime conventional imaging does not give a complete diagnosis which gives us difficulties while treating those patients. EUS gives us helping hand in some of those patients. To study the characteristics of the lesion of pancreas by linear EUS in a tertiary care hospital. METHODS: This study was done from August 2015 to July 2016 in the Department of Medical Gastroenterology, Government Stanley Medical College Hospital. Patients who were diagnosed to have pancreatic lesions with diagnostic dilemmas were included in this study. All the cases were referred to us from other deparments and other institutions also evaluation was done with olympus linear echoendoscope. The findings were recorded and FNA was done whenever necessary with 22 or 25 G needle.

RESULTS: Total number of patients were 66 out of which 48 (72.7%) patients were males and the remaining (27.3%) were females. The age ranged from 16 to 77 (mean 45.8). There were 17 (25.8%) patients in the age group of 51–60, 16 (24.2%) patients in the 41–50 group, 13 (19.7%) patients in the 31–40 group and 4, 6, 8, 2 in 11–20, 21–30, 61–70 and 71–80 groups respectively. EUS showed features of acute pancreatitis with fluid collection in 12 patients, chronic pancreatitis in 21 patients.16 patients had solid mass lesion out of which 13 (81.1%) had features of malignancy and 22 had cystic lesion out of which 8 (36.4%) had features of pseudocysts and the remaining 14 (63.6%) showed features of cystic tumour of pancreas on EUS. 4 patients suspected to have rap with conventional imaging showed features of chronic pancreatitis in 3 and cystic lesion in tail in 1 patient. CONCLUSIONS: EUS scores over conventional imaging with regards to pancreas. It helps us to tide over the diagnostic dilemmas in certain cases. Conflict of Interest: None declared.




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P377: EVALUATION OF PANCREATIC MASS LESION WITH EUS - OUR EXPERIENCE

We aimed to evaluate ASGE criteria for prediction of choledocholithiasis in patients undergoing cholecystectomy.

Murali Ramamoorthy, Malarvizhi Murugesan, Chitra Shanmugam, Revathy Shanmugam, Venkateswaran Arcot Rajeswaran, N. Arun, Hardik Rughwani

METHODS: We retrospectively analysed data of patients

Government Stanley Medical College, Medical Gastroenterology, Chennai, India

AIMS: Patients with acute and chronic pancreatitis frequently presents with mass lesion. It is difficult to differentiate between inflammatory and malignant mass clinically and with routine imaging. EUS renders a helping hand in this group of patients. To evaluate the characteristics of the mass lesion of pancreas by linear EUS in a tertiary care hospital. METHODS: This study was done from August 2015 to July 2016 in the Fepartment of Medical Gastroenterology, Government Stanley Medical College Hospital. Patients who were diagnosed to have pancreatic mass lesions with diagnostic dilemmas were included in this study. All the cases were referred to us from other deparments and other institutions also. Evaluation was done with olympus linear echoendoscope. The findings were recorded and FNA was done whenever necessary with 22 or 25 G needle.

RESULTS: Total number of patients with mass lesion were 35. There were 24 (68.6%) males and 11 (31.4%) females and the mean age was 49.51. Out of 35 patients, 15 (42.8%) patients had solid lesion and 20 (57.2%) had cystic lesion. EUS showed features of inflammatory mass in 3 (20%) cases and malignancy in 12 (80%) cases in the solid lesion group. It also showed features of pseudocyst in 7 (35%) patients and cystic tumour in 13 (65%) patients. FNA was done in 26 patients and cytology and fluid analysis were done. FNA came as positive for malignancy in 7 (26.9%) patients and 8 (30.7%) showed inflammatory features in the smear. Cystic fluid showed high amylase in 6 patients and high cea in 11 patients. CONCLUSIONS: Hence EUS helps in delineating the patients with benign and malignant lesion. This also helps to avoid unwarranted surgeries as well. Conflict of Interest: None declared.

undergoing cholecystectomy for symptomatic cholelithiasis at Asian Institute of Gastroenterology, Hyderabad, India from Jan 2014 to July 2016. All patients who underwent pre-operative EUS and/or ERCP were included in the analysis.

RESULTS: A total of 387 patients who underwent preoperative EUS and/or ERCP were included in the analysis. Of which 92, 262 and 33 patients were with ASGE high, intermediate and low-probability for choledocholithiasis. In high probability – 49 (53.26%) were found to have choledocholithiasis with accuracy of 81.4% (Specificity [SP] - 86.1% and Sensitivity [SN] 62.8%). In intermediate probability and low probability - 26 (11%) and 3 (9.1%) patients were found to have choledocholithiasis with accuracy of 25.6% (SP- 23.6% and SN - 33.3%) and 72.9% (SP90.3% and SN - 3.85%) respectively. Presence of cholangitis, high bilirubin, raised SGOT, and dilated CBD on transabdominal ultrasounds are significantly associated with choledocholithiasis (P < 0.05). CONCLUSIONS: Pre-operative stratification for assessing risk of choledocholithiasis in patients with symptomatic cholelithiasis can be done by using ASGE criteria. Patients with intermediate probability for choledocholithiasis should undergo EUS before therapeutic ERCP. Conflict of Interest: None declared.

P379V: ENDOSCOPIC ULTRASOUND OF SPLENIC ARTERY PSEUDOANERYSM Piyush Somani1, Malay Sharma2 1

Jaswant Rai Speciality Hospital, Gastroenterology, Meerut, India and 2Jaswant Rai Speciality Hospital, Meerut, India

AIMS: A 42-year-old man was referred from an outside hospital with a recent episode of acute pancreatitis and hematemesis for evaluation of a cystic lesion in the body of the pancreas that was noted on computerized tomography (CT) (abdomen). Upper gastrointestinal endoscopy was normal. METHODS: Linear endoscopic ultrasonography (EUS) per-

P378: VALIDATION OF ASGE CRITERIA FOR PREDICTION OF CHOLEDOCHOLITHIASIS IN PATIENTS UNDERGOING CHOLECYSTECTOMY Nitin Jagtap1, Jahangeer Basha1, Mohan Ramchandani1, Sundeep Lakhtakia1, Rajesh Gupta1, Rakesh Kalapala1, G. V. Rao2, Rebala Pradeep2, D. Nageshwar Reddy1 1 Asian Institute of Gastroenterology, Medical Gastroenterology, and 2Asian Institute of Gastroenterology, Surgical Gastroenterology, Hyderabad, India

AIMS: Inability to detect choledocholithiasis pre-operatively can lead to complications such as cholangitis or pancreatitis.

formed from the stomach revealed a 25 mm 9 22 mm cysticappearing lesion in the body of pancreas. The lesion had a thick outer hypoechoic wall (12 mm), with a central anechoic area that appeared as a ‘‘donut’’. The surrounding pancreatic parenchyma was oedematous with peripancreatic fluid collection consistent with an acute attack of pancreatitis. On colorflow and Doppler US imaging, vascular flow was seen in the central anechoic area which confirmed the vascular nature of lesion.

RESULTS: EUS fine needle aspiration was not performed in view of possibility of aneurysm and presence of coexisting acute inflammation. Patient underwent CT (abdomen) with contrast which revealed a 30 X 26-mm splenic artery


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pseudoaneurysm. The aneurysm was successfully embolized, and, at 6-months follow-up, he remained asymptomatic.

CONCLUSIONS: The most common abdominal visceral vessel affected by aneurysmal disease is the splenic artery which has been attributed to acquired derangements of the vessel wall over time. The incidence of pseudo aneurysm in chronic pancreatitis is around 6% to 9%. US and CT are commonly used for evaluating vascular aneurysms. Sometimes, on these investigations, aneurysms can masquerade as pancreatic-cystic lesions. In such cases, EUS can help in final diagnosis. The aneurysms had a characteristic donut-like appearance at EUS: a thick outer wall with a central anechoic area. In a study by Varadarajulu et al, out of 413 pancreatic cystic lesions four were found to be aneurysms. Awareness of aneurysm is necessary as inadvertent FNA during EUS may lead to serious complications. Conflict of Interest: None declared.

P380: UTILITY OF ENDOSCOPIC ULTRASONOGRAPHY IN ETIOLOGICAL DIAGNOSIS OF FIRST EPISODE OF IDIOPATHIC ACUTE PANCREATITIS Parag Dashatwar, Sharat Putta Krishna Institute of Medical Sciences, Hyderabad, India

AIMS: To prospectively evaluate the ability of endosonography (EUS) to identify various causative pancreato-biliary lesions in patients with idiopathic acute pancreatitis (IAP). METHODS: EUS was performed after four to six week of first attack on consecutive patients with IAP. A radial scanning echoendoscope was used to look for biliary microlithiasis, sludge, anatomical anomalies and changes of chronic pancreatitis according to the Rosemont criteria.

RESULTS: A total of 40 patients were included. EUS positivity was found in 25 (62.5 %) patients. It included common bile duct (CBD) calculus in 4 (10 %), CBD sludge in 3 (7.5 %), gallbladder calculus in 2 (5 %), gallbladder sludge in 2 (5%), and chronic pancreatitis (CP) in 14 (35 %) patients. Fifteen patients had a normal study and eight patients had indeterminate CP. CONCLUSIONS: EUS has a reasonable diagnostic yield in patients with first episode of IAP. CP and biliary lithiasis are the most frequent positive findings on EUS. Conflict of Interest: None declared.

P381: THE DIAGNOSTIC YIELD OF ENDOSCOPIC ULTRASONOGRAPHY IN PATIENTS WITH SUSPECTED CHOLEDOCHOLITHIASIS Istvan Hritz1, Jahangeer Basha2, Sundeep Lakhtakia2, Rajesh Gupta2, Mohan Ramachandani2, Rakesh Kalapala2, P. Pal2, Rao V. Guduru2, D. Nageshwar Reddy2 cs-Kiskun County University Teaching Hospital, Ba Kecskemet, Hungary and 2Asian Institute of Gastroenterology, Gastroenterology, Hyderabad, India 1

AIMS: The likelihood of CBD stones can be prognosticated by the presence of various clinical predictors, however the sensitivity and specificity of these factors is moderate. Endoscopic ultrasonography (EUS) has been shown to be a noninvasive precise test for the detection of CBD stones. Our aim was to assess the diagnostic yield of EUS in patients with suspected choledocholithiasis in a high-volume center during the period of one-month. METHODS: Prospective study of patients with cholelithiasis and clinical symptoms or abnormal liver function tests who underwent transabdominal ultrasonography (USG) that could not detect CBD stones (except in one case) were categorized and divided into an intermediate- and high likelihood groups according to the clinical predictors (i.e. serum bilirubin, age, CBD diameter) defined by the American Society of Gastrointestinal Endoscopy (ASGE) guidelines and referred for radial EUS.

RESULTS: Total of 26 patients, 14 females and 12 males (average age of 40.8 17.3 and 51.1 14.9, respectively) were assessed. CBD stones were detected by EUS overall in 17 (65.4%) patients: 61.5% of patients (8/13) in the intermediate likelihood- and 69.2% of patients (9/13) in the high likelihood group. The size and the number of detected CBD stones in all patients were confirmed by the followed therapeutic endoscopic retrograde cholangio-pancreatography (ERCP) except in one case where a preampullary calcific stenosis was described as a calculus during the EUS. Two-month follow up of those patients with no CBD stones detected on EUS revealed no clinical findings suspicious for biliary obstruction. CONCLUSIONS: EUS is a highly sensitive and accurate diagnostic tool for the detection and evaluation of CBD stones also in patients with previous normal USG findings. Further study is needed to assess the potential correlation of clinical data with EUS findings in the detection of suspected choledocholithiasis. Conflict of Interest: None declared.



P382: ENDOSONOGRAPHY HAS A HIGH DIAGNOSTIC ACCURACY IN DIFFERENTIATING INFLAMMATORY FROM MALIGNANT PANCREATIC HEAD MASSES IN PATIENTS WITH CHRONIC PANCREATITIS Sawan Bopanna, Shallu Midha, Rajan Dhingra, Rajesh Padhan, Pramod Kumar Garg All India Institute of Medical Sciences, New Delhi, India

AIMS: To evaluate the role of Endosonography (EUS) in differentiating malignant from inflammatory head masses in patients with CP. METHODS: Patients records were reviewed from a prospectively maintained database from January 2009 to August 2016. Patients with CP with pancreatic head masses on imaging were subjected to EUS and if required fine needle aspiration cytology (FNAC). Sensitivity and specificity of EUS to differentiate malignant and inflammatory masses were calculated.

RESULTS: 92 patients presented with a pancreatic head mass on CT/MRI and underwent EUS to rule out malignancy. Mean age at presentation was 43.37 10.9 years. 121 (85.1%) were male. 63.1% had alcoholic and 36.8% had idiopathic CCP. Mean duration of disease was 35.8 51.1 months. No definite mass was discernible in 38/92 (41.7%). 60/92 (65.2%) were found to have mass. FNA was done in 36/60 (60%) which revealed 30/60 (50%) to be inflammatory and 6/60 (10%) to be malignant. Follow up of those with inflammatory mass over mean duration of 14.8 12.6 months showed no evidence of malignancy. All patients with FNA showing malignancy were confirmed to be malignant on follow up. Thus, sensitivity and specificity of EUS FNA was found to be 100%. 24 patients did not undergo FNA. Strong suspicion of malignancy was present in 8/24 (33.3%). 1/ 24 (4.1%) patient was advised surgery but was lost to follow up and eventually expired due to malignancy. 5/7 (71.4%) were eventually found to have malignancy on surgery/follow up. Due to pain, 4 patients underwent surgery which revealed inflammatory mass. 12/24 (50%) did not undergo surgery and remained well over mean duration of 13 15.1 months confirming benign nature. Sensitivity and specificity of EUS alone was 100% and 88.8% respectively. CONCLUSIONS: Endosonography has high sensitivity and specificity for differentiating inflammatory and malignant pancreatic head masses in patients with CP. Conflict of Interest: None declared.


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P383: ROLE OF ENDOSCOPIC ULTRASOUND IN DIAGNOSIS AND TREATMENT OF PANCREATIC TUMORS Ashraf Sobhy Zakaria National Cancer Institute, Cairo University, Cairo, Egypt

AIMS: To evaluate the role of EUS in diagnosis and treatment of pancreatic tumors prospectively for 2 years study 2013– 2015. METHODS: Prospective study including 70 patients who presented with pancreatic tumors underwent EUS at the endoscopy unit at Faculty of Medicine Cairo University and National Cancer Institute, Cairo University. EUS and EUS-FNA were performed by a single endoscopist. It was done under deep sedation using a Pentax linear array Echoendoscope type EG-3870UTK attached to a high end Hitachi Ultrasound AVIUS machine. A detailed description of the biliary system and pancreas was done, EUS-FNA was done by an Echotip needles, 22G or 19G. Material was spread over a glass slide and fixed by 95% alcohol, then sent to a single experienced cytologist. Immunohistochemistry was done if needed. The kappa values are evaluated according to arbitrary “benchmarks”.

RESULTS: out of 70 patients; Males were 32 (46%) and females were 38 (54%). There were 20 patients with benign disease and 50 patients with malignant disease. Median age was 55 years (range 32_73 years). The following results showing the accuracy of the EUS in detecting malignant pancreatic tumors; Sensitivity: 96.0%, specificity: 75%, PPV: 90.6%, NPV: 88.2%, accuracy: 90.0%. Also the results of elastography show that; the Sensitivity: 94.0%, specificity: 80%, PPV: 92.2%, NPV: 84.2%, accuracy: 90.0%. Interventional EUS (EUS guided drainage) was done in 7 cases of pancreatic cystic tumors. CONCLUSIONS: EUS has a major role in not only in diagnosing and staging pancreatic tumor but also as a therapeutic tool for patients with pancreatic tumors. EUS has the best diagnostic accuracy in patients with small pancreatic lesions especially neuroendocrine tumors EUS is the gold standard in combination of superior detection, good staging, tissue diagnosis and potential therapy in pancreatic tumors. Conflict of Interest: None declared.


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ENDOSCOPIC ULTRASOUND: ENDOSCOPY: EUS INTERVENTIONAL HEPATOBILIARY P384: EVALUATION OF PAIN SYNDROME AFTER CELIAC PLEXUS BLOCKADE WITH SUBSEQUENT NEUROLYSIS IN PATIENTS WITH CHRONIC ABDOMINAL PAIN SYNDROME IN THE UPPER ABDOMINAL CAVITY Mikhail Burdyukov1, Mikhail Davydov1, Andrew Nechipai2, Ilia Yurichev1, Marina Isakova1, Boris Dolgushin1 1

N.N. Blokhin Russian Cancer Research Center, and 2Russian Medical Academy of Postgraduate Education of Russian Ministry of Healthcare, Moscow, Russia

AIMS: To study the dynamics of pain syndrome after endoscopic neurolysis and reveal most common response pattern to the method. METHODS: In cases of 42 patients we enrolled in the study, with 60 interventions under endosonography performed to alleviate pain syndrome. Before intervention and the day after, as well as at time points at 1, 2, 4, 6 weeks after intervention, questionnaire with visual-analog scale were assessed. Statistical analysis of the date along with most common response patterns to the intervention were performed.

RESULTS: Analysis of difference between baseline pain syndrome level and pain level immediately after the procedure revealed that in one case pain level did not change, in 2 cases pain level insignificantly increased and decreased in 57 patients. Decrease of pain syndrome ranged between 5 and 90 scores, with mean decrease of 55.5 scores, mediana 60 scores. In quarter patients pain decrease ranged between 5 and 40 scores with range of decrease between 70 and 90 scores in other quater. Based on that, we concluded that in 95% patients (57 out of 60), neurolysis under endoscopic control decrease the pain that makes that the procedure is effective method of decreasing: the patients; mediana magnitude of pain syndrome decrease was 60 scores that proves significance of the effect on pain syndrome.

CONCLUSIONS: In this part of the study pain syndrome dynamics was assesed on the base of questionnaire with visualanalog cale. Results of the study reveales that pain syndrome statistically significantly decrease in comparison with the baseline throughout the observation. There is a tendency to gradual increase in pain syndrome without reaching statistical significance. Most common patterns of dynamics of pain syndrome after the procedure were revealed that will help to predict results of dynamics after the procedure. Conflict of Interest: None declared.


P385: FACTORS INFLUENCING DYNAMICS OF PAIN AS METHOD OF ASSESSING OF EFFECTIVES OF CELIAC PLEXUS BLOCK AND NEUROLYSIS IN PATIENTS WITH CHRONIC UPPER ABDOMINAL PAIN SYNDROME Mikhail Burdyukov1, Mikhail Davydov1, Andrew Nechipai2, Ilia Yurichev1, Marina Isakova1, Boris Dolgushin1 1 N.N. Blokhin Russian Cancer Research Center, and 2Russian Medical Academy of Postgraduate Education of Russian Ministry of Healthcare, Moscow, Russia

AIMS: Asses factors influencing the dynamics of severity of abdominal pain syndrome after EUS-CPN in patients with chronic pain syndrome in upper abdominal cavity. METHODS: 42 patients were enrolled in the study with 60 interventions of EUS-CPN performed under endosonography control to alleviate pain syndrome. Questionnaire with visual analog scale for pain assessment was filled out before EUS-CPN on the day of procedure as well as 1, 2, 4, 6 weeks afterward. Due to differences in response to standard EUS-CPN clinical factors and procedural factors potentially influencing effectiveness of the procedure were assessed.

RESULTS: Multifactrorial analysis (General Linear Model) of association of dynamics of pain severity with clinical factors revealed that pre-procedure visual analog scale score was the best measurement of status of the patient assessed using ECOG (P = 0.026), cancer size (р=0.08). VAS score dynamics after 8 weeks were more pronounced in different age groups (р=0.08) and different diagnosis groups (р=0.097), while ECOG was nonsignificant (р=0.2). Multifactorial anlysis including clinical factors and treatment manipulations revealed that age (P = 0.0018), and volume of neurolytic agent (ethanol) (р=0.025) were independently associated with effectiveness of the procedure. CONCLUSIONS: Visual-analog questionare assessing pain severity helps asses effectiveness of EUS-CPN and dynamics of pain syndrome after the procedure. The following factors influenced the severity of pain syndrome: pain syndrome significantly decreased through the whole study with nonsignificant tendency of increasing of pain syndrome. We revealed the clinical factors affecting the results of the study: diagnosis, cancer stage, general status of the patient based on ECOG scale and history of abdominal surgery. The following factors affected the final outcome of intervention: large volume of anesthetic with naropin being more effective than marcain, large volume of ethanol as well as bilateral injection of ethanol with mandatory infiltration of celiac ganglions. Conflict of Interest: None declared.



P386V: FEASIBILITY OF THE CONVERSION OF PERCUTANEOUS CHOLECYSTOSTOMY TO INTERNAL TRANSMURAL ENDOSCOPIC ULTRASOUND-GUIDED GALLBLADDER DRAINAGE Tanyaporn Chantarojanasiri1,2, Saburo Matsubara1,3, Hiroyuki Isayama1, Yousuke Nakai1, Naminatsu Takahara1, Suguru Mizuno1, Hirofumi Kogure1, Ryunosuke Hakuta4, Yukiko Ito4, Minoru Tada1, Kazuhiko Koike1


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P387V: ENDOSCOPIC OPERATIONS IN TUMOROUS OBSTRUCTIVE JAUNDICE Konstantin Ryabov, Maria Rudakova Municipal Clinical Hospital No 57, Oncology, Moscow, Russia

AIMS: To evaluate possibilities of endoscopic interventions for decompression in malignant obstruction of biliary tree.

1

METHODS: 106 patients with obstructive jaundice from

2

01.06.2015 to 31.05.2016. Cancer of periampullary zone was the reason of jaundice in 62 patients, tumor of the proximal parts of biliary ducts - in 5 patients, metastatic affection of hepatoduodenal ligament due to progression of tumors of other localizations - in 39 patients. Transpapillary stenting with metallic self-expandable stents were performed in 70 patients, formation of puncture anastomoses under the control of endoscopic ultrasound examination - in 11 patients, antegrade stenting - in 2 patients, transcutaneous transhepatic cholangiostomy - in 23 patients (including 11 patients in whom formation of anastomoses failed). Special metallic self-expandable stents manufactured by «S&G Biotech Inc.», South Korea, were used in all cases.

University of Tokyo, Gastroenterology, Tokyo, Japan, Police General Hospital, Internal Medicine, Bangkok, Thailand, 3Tokyo Metropolitan Police Hospital, Gastroenterology, Tokyo, Japan and 4Japanese Red Cross Medical Center, Gastroenterology, Tokyo, Japan

AIMS: Percutaneous cholecystostomy (PTGBD) is the treatment of choice for acute cholecystitis in surgically unfit patients. However, the removal of the PTGBD tube after symptoms resolution results in 41–46% recurrence. This study aims to demonstrate the feasibility of the conversion of PTGBD to transmural Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using plastic stents in patients unfit for cholecystectomy. METHODS: We reviewed six patients who underwent internal transmural EUS-GBD as a conversion from PTGBD. The patients’ age ranged from 61 to 88 years old (median 76 years old), with the underlying of malignancy in 4 patients. All of them received PTGBD for the treatment of acute cholecystitis. One or two 7Fr double pigtail plastic stent insertion with or without temporary endoscopic naso-gallbladder drainage (ENGBD) insertion was performed. The EUS-GBD procedures were as follow; after the contrast diluted with saline injection through the PTGBD, direct puncture of the gallbladder was performed using 19G EUS-FNA needle, confirmed both by the EUS image as well as fluoroscopic image. The first guidewire is inserted into the stylet channel and coiled inside the gallbladder lumen. The cholecysto-enteric fistula was initially dilated using electric cautery dilator, followed by the second guidewire insertion through the double lumen cannula. Subsequently, the fistula was further dilated by the balloon dilator, and two double pigtail plastic stents were inserted.

RESULTS: The technical success and clinical success were achieved and the PTGBD tubes were subsequently removed in all patients. All ENGBD tubes were removed within five days after insertion. Bile leak with peritonitis was demonstrated in one case which was treated conservatively. No recurrent cholecystitis was seen. CONCLUSIONS: The conversion of percutaneous cholecystostomy to internal transmural EUS-GBD with plastic stents is feasible for patients unfit for cholecystectomy. Conflict of Interest: None declared.

RESULTS: Transpapillary stenting was performed in 70 patients representing 92% of all ERPCG (endoscopic retrograde pancreatocholangiography). The following types of puncture anastomoses under the control of endoscopic ultrasound examination: Type of anastomosis HepaticogastroCholedochoduodenoHepaticoenteroCholecystoenteroTotal

Total attempts

Technical effectiveness, abs/%

11 6 3 1 21

4/37 4/67 2/67 1/100 11/52

Puncture of appropriate duct under the control of endoscopic ultrasound examination was performed in 100% cases, but migration of the cord took place in 3 cases, and adequate bouginage of the puncture canal failed in 7 cases. Proportion of effective intervention is increased with gain in experience. Proportion of successful endoscopic interventions composed 78%.

CONCLUSIONS: Endoscopic operations in tumorous obstructive jaundice are effective in great majority of the cases, and they can be used as single option in whatever anatomical situation with gain in experience. Conflict of Interest: None declared.


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P388: EUS GUIDED GALL BLADDER DRAINAGE IN SEVERE LIVER DISEASE: ARE WE READY FOR EUS IINTERVENTIONS IN THESE CRITICALLY ILL PATIENTS Kapil D Jamwal, Manoj Sharma, Rakhi Maiwall, Barjesh Chander Sharma, Shiv Kumar Sarin Institute of Liver and Biliary Sciences, Hepatology, New Delhi, India

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 AIMS: Endoscopic ultrasonography guided biliary drainage (EUS-BD) is an alternative to failed ERCP. It is performed either by transmural (EUS-choledocoduodenostomy, EUS-CDS or hepatogastrostomy, EUS-HGS; EUS-BD-TM) or transpapillary (antegrade or rendezvous; EUS-BD-TP) techniques. Data regarding efficacy of these modalities is limited. To compare stent patency after EUS-BD via TM or TP approach using metal stents in inoperable malignant biliary obstruction (MBO). METHODS: Data of patients undergoing EUS-BD using metal

AIMS: Acute calculous cholecystitis with impending gall bladder (GB) perforation in presence of severe liver disease (ACLF and decompensated liver disease) is difficult to manage. In such patients emergency cholecystectomy has high mortality and percutaneous gallbladder drainage is difficult to perform due to presence of ascites. EUS guided cholecystogastrostomy (EUSCCG) can be used as a life saving technique in such group of patients with severe liver disease.There are no reports of EUSCCG in patients with severe liver disease. METHODS: We present four cases of severe liver disease with acute calculous cholecystitis who underwent EUS guided gall bladder drainage as a life saving maneuver.

RESULTS: Four cases of severe liver disease with MELD score of 24, 25, 24 and 26 respectively presented with acute cholecystitis and systemic sepsis (TLC 20430, 24317, 19876 and 23543 mm3) respectively, their INR were 2.3, 2.7, 2.1 and 2.6 respectively and two had shock requiring inotropes. USG abdomen showed GB stones, hugely distended GB with moderate ascites and abdominal wall collaterals. All were high risk for percutaneous drainage, they all were taken up for EUS guided GB drainage. The GB was accessed from antrum with a linear EUS scope and punctured with a 19G access needle, after passing the guidewire the tract was dilated with CRE balloon (6 F and 8 F) in two and with Sohendra dilators upto 10F in remaining two patients. In three patients plastic stents (double pig tail) were placed and in the fourth a NAGI stent (Taewong ltd) was palced. All the patients recovered with a mean hospital stay of 7 days and with a minimum follow up of 90 days. CONCLUSIONS: EUS guided biliary procedures in severe liver disease are challenging but life saving and hence expanding the role of EUS in these patients is to be explored. Conflict of Interest: None declared.

P389: STENT PATENCY IN ENDOSCOPIC ULTRASOUND GUIDED TRANSMURAL VS TRANSPAPILLARY BILIARY DRAINAGE Ravindra Gaadhe, Amol Bapaye, Mahesh Mahadik, Nachiket Dubale, Harshal Prabhakar Gadhikar, Siva Sankar Reddy Gangireddy Deenanath Mangeshkar Hospital, Shivanand Desai Center for Digestive Disorders, Pune, India

stents for unresectable MBO after failed ERCP from 2011 to 2015 was retrospectively collected. Data included etiology and disease stage, laboratory, imaging, reason for failed ERCP, EUSBD technique (TM / TP). Follow up was obtained till recurrence of jaundice, re-intervention or death, whichever was earlier. Statistical analysis was performed using Kaplan-Meier graph and log-rank test. P < 0.05 was considered significant.

RESULTS: Total ERCP’s = 4064; EUS-BD = 108 (2.6%); EUS-BD using metal stents for MBO = 71; follow up available = 56. EUSBD-TM = 33 & EUS-BD-TP = 23. Both groups comparable for demographic and clinical characteristics. Overall median stent patency = 77 days (IQR 48 - 228); median patency in TM group = 69 days (IQR 51 - 240) vs TP = 87 days (IQR 42 - 213) (P = 0.35). Stent related adverse events TP = 8 vs TM = 4 (P = 0.080); stent migration - TP = 0 vs TM = 2; stent occlusion or cholangitis (TP = 8 vs TM = 2).

CONCLUSIONS: Outcomes of EUS-BD by TM or TP approach are comparable in terms of stent patency and frequency of adverse events. Conflict of Interest: None declared.

P390: EUS-GUIDED CHOLEDOCHODUODENOSTOMY FOR MALIGNANT DISTAL BILIARY OBSTRUCTION AFTER FAILED ERCP Praveer Rai1, CR Lokesh2, Vivek Anand Saraswat2 1 Sanjay Gandhi Postgraduate Institute, Gastroenterology, and 2Sanjay Gandhi Postgraduate Institute, Lucknow, India

AIMS: Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) is an alternative procedure to percutaneous transhepatic biliary drainage (PTBD) for patients in whom ERCP has failed. The aim of this study was to assess the feasibility, clinical efficacy and safety of EUS-CDS as a palliative treatment in patients with distal malignant biliary obstruction after failed ERCP. METHODS: Prospective analysis of all patients with distal malignant biliary obstruction requiring biliary drainage who, between August 2015 and July 2016, underwent EUS-CDS using partially covered metal stent (WallFlex, Boston Scientific) after failed ERCP, at Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. Technical success, clinical success (more than 50% reduction in bilirubin from baseline after 2 weeks) and adverse events were assessed.


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 RESULTS: Sixteen patients (M/F 9/7; median age 60 years) underwent EUS-CDS. ERCP failure was due to failed cannulation of papilla in 10 patients and remaining 6 had gastric outlet obstruction. The procedure was technically successful in 15/16 patients with procedural time range of 20–45 minutes. Clinical success was achieved in all the patients. Baseline mean bilirubin was 19.78 mg/dL (range 6–35 mg/dL), 2 weeks after procedure was 6.5 mg/dL (range 2–12 mg/dL). One patient had hemobilia following the procedure requiring 2 units of blood transfusion, 2 patients had bile leak requiring therapeutic paracentesis, during follow up of up to 2 months, one patient developed stent block cholangitis and died. CONCLUSIONS: EUS-CDS using partially covered metal stent is feasible, safe with high technical and clinical success rates. Conflict of Interest: None declared.

P391V: ENDOSCOPIC ULTRASOUND-GUIDED TRANSMURAL GALLBLADDER DRAINAGE IS SUPERIOR TO ENDOSCOPIC TRANSPAPILLARY GALLBLADDER DRAINAGE FOR ACUTE CHOLECYSTITIS Saburo Matsubara1,2, Tanyaporn Chantarojanasiri1,3, Yousuke Nakai1, Hiroyuki Isayama1, Natsuyo Yamamoto1, Ryunosuke Hakuta1,4, Tomoka Nakamura1, Yuki Kawaji1, Tatsuya Sato1, Tsuyoshi Takeda1, Gyotane Umefune1, Kei Saito1, Takeo Watanabe1, Kaoru Takagi1, Tomotaka Saito1, Rie Uchino1, Naminatsu Takahara1, Suguru Mizuno1, Hirofumi Kogure1, Yukiko Ito4, Minoru Tada1, Kazuhiko Koike1 1 University of Tokyo, Department of Gastroenterology, Tokyo, Japan, 2Tokyo Metropolitan Police Hospital, Department of Gastroenterology, Tokyo, Japan, 3Police General Hospital, Depaetment of Internal Medicine, Bangkok, Thailand and 4Japanese Red Cross Medical Center, Department of Gastroenterology, Tokyo, Japan

AIMS: Endoscopic ultrasound-guided transmural gallbladder drainage (EUS-GBD) and endoscopic transpapillary gallbladder drainage (ETGBD) are the alternatives to percutaneous drainage for acute cholecystitis patients unfit for emergency cholecystectomy. However, the usefulness of EUS-GBD and ETGBD has not been well compared. METHODS: Thirty-one patients with acute cholecystitis who were inapplicable to receive emergency cholecystectomy and underwent EUS-GBD consecutively from September 2011 to September 2016 were recruited as a clinical trial. After the gallbladder puncture using 19G EUS-FNA needle from the duodenum or gastric antrum, the tract was dilated using electric cautery or balloon catheter, followed by insertion of double-pigtail plastic stent with or without naso-cystic tube. The data were compared with ETGBD cases performed in 257 patients in the routine standard ERCP using double pigtail plastic stent or naso-cystic tube from 1998 to September 2014.


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The technical feasibility, efficacy, and safety of EUS-GBD and ETGBD were compared.

RESULTS: Median age (range) of the patients was similar in both groups; 71 years old (40–88) in EUS-GBD group and 77 (32– 100) in ETGBD group. Patients using antithrombotic drugs were more frequent in ETGBD group (45%) than EUS-GBD group (13%). Ascites were found in about 7% in both groups. The procedures were performed as a bridging to surgery in about 40% in both groups. Concomitant CBD stones were more frequently seen in ETGBD group (31%) than in EUS-GBD group (7%). Technical and clinical success rate were significantly higher in EUS-GBD group (100% and 94%, respectively) compared to ETGBD group (77% and 72%, respectively). Adverse events in both groups were not significantly different (13% in EUS-GBD vs 16% in ETGBD). CONCLUSIONS: In our experiences, EUS-GBD was considered superior to ETGBD in terms of the technical feasibility and efficacy with similar safeness. Conflict of Interest: None declared.

P392V: EUS-GUIDED CHOLEDOCODUODENOSTOMY AND STENTING AFTER TOTAL GASTRECTOMY Fen Wang, Xiaoyan Wang, Li Tian, Dinghua Xiao Third Xiangya Hospital of Central South University, Changsha, China

AIMS: We aim to assess the efficacy and safety of a combination of EUS-guided choledocoduodenostomy and stenting after total gastrectomy. METHODS: Male patient, 52 years, was admitted in Feb 12nd due to “1 year after total gastrectomy for stomach cancer, skin and sclera jaundiced for half month”. Abdominal CT scan and MRCP showed biliary and pancreatic duct expansion. Vater´s papilla was not found by duodenal colonoscopy and repeated direct observation, and ERCP was not implemented. We firstly found dilated left hepatic duct with EUS, and then punctured the left hepatic duct by using 19G needle. After successfully aspirating bile juice, we insert guide wire along the puncture needle, then insert needle knife along the guide wire. Radiography shows the expansion of intrahepatic duct. We insert cyst-knife (Cystotome) along the guide wire to establish the hepatoduodenal channel, and then implanted 6 cm x 10 mm membrane-covered metallic stents between liver and duodenum successfully.

RESULTS: Jaundice and serum amylase rapidly reduced for post-EUS-Guided stenting, subsequent chemotherapy and chemo-hyperthermia were smoothly implemented. CONCLUSIONS: EUS-guided choledocoduodenostomy after total gastrectomy stenting is safe and effective. Conflict of Interest: None declared.


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P393V: COMPLETE ENDOSCOPIC MANAGEMENT OF POST WHIPPLE’S BILIARY ANASTOMOTIC STRICTURE WITH CHOLEDOCHOLITHIASIS AND ITS RESULTANT COMPLICATION OF POST-PROCEDURE BILIOMA

P394: EUS-GUIDED BILIARY DRAINAGE: DIAGNOSIS, ACCESS ROUTE AND SUCCESS RATE OF STENT PLACEMENT AMONG PATIENTS WITH MALIGNANT BILIARY OBSTRUCTION IN CIPTO MANGUNKUSUMO NATIONAL GENERAL HOSPITAL

Amol Bapaye, Nachiket Dubale, Rajendra Pujari, Mahesh Mahadik, Tarun Bharadwaj, Siva Sankar Reddy Gangireddy, Rahul Lokhande

Dadang Makmun, Achmad Fauzi, Murdani Abdullah

Deenanath Mangeshkar Hospital, Shivanand Desai Center for Digestive Disorders, Pune, India

AIMS: EUS guided biliary drainage (EUS-BD) is an accepted alternative of biliary drainage of malignant biliary obstruction when ERCP fails due to surgically altered anatomy. EUS-BD for stone disease has been less frequently described. EUS-BD may result in perforation with biliary peritonitis and bilioma formation Aim - This case describes EUS guided dilatation of post Whipple’s Choledocholjejunostomy (CJ) stricture and CBD stone clearance and also describes successful EUS guided drainage of post-procedure bilioma. METHODS: 47 years old gentlemen underwent Whipple’s surgery for pancreatic head adenocarcinoma 3 years ago. He presented with intermittent fever and jaundice of 2 months duration. MRCP showed CJ stricture with a stone proximally. Single balloon enteroscope assisted ERCP failed due to acute bend in the afferent loop. Left hepatic duct (LHD) was accessed under EUS guidance using a 19G needle and a 0.032-inch floppy tip guidewire was negotiated across the CJ stricture into the jejunum. Cholangiogram confirmed MRCP findings. CJ stricture was dilated to 12 mm using CRE balloon and CBD stone was pushed using a biliary extractor into the jejunum. A stent was not placed in view of difficulty of subsequent stent removal at a later date. Check cholangiogram showed complete CBD clearance.

RESULTS: Three days post-procedure patient had fever. Ultrasonography showed subhepatic collection in lesser sac. Possibility of post stricture dilatation bilioma was considered. EUS guided aspiration revealed bile; and the collection was drained into the stomach using 3 DPT stents. Patient’s fever resolved and follow up USG showed complete clearance of collection. Further follow up at 6 weeks revealed no recurrence of collection. CONCLUSIONS: EUS guided dilatation of biliary anastomotic stricture may lead to bile leak with resultant bilioma. EUS guided transgastric drainage of bilioma is feasible and safe and may avoid surgery in these otherwise difficult to treat patients. Conflict of Interest: None declared.

Universitas Indonesia, Department of Internal Medicine, Jakarta Pusat, Indonesia

AIMS: Endoscopic ultrasounds-guided biliary drainage (EUSBD) is a well-recognized biliary drainage method after failed endoscopic biliary drainage by ERCP in patients with biliary obstruction. EUS-BD is the only preferred method as an alternative to PTBD or surgical intervention which is associated with higher complications. This study aimed to evaluate the demography, diagnosis, access route, and success rate of stent placement. METHODS: We conducted a study among 24 patients with malignant biliary obstruction who underwent EUS-BD after failed ERCP between January 2015 until August 2016. We placed trans-luminal or trans-papillary stent with EUS-guided rendezvous technique.

RESULTS: Among 24 patients, 12 patients (50%) were male and 12 patients (50%) were female. Patients age ranged from 37 to 80 years (mean 59 years). Twelve patients (50%) were aged < 60 years and 12 patients (50%) were >60 years. Thirteen patients (54.2%) were diagnosed as tumor in the head of pancreas, while 9 patients were diagnosed as tumor of ampulla of Vater (37.5%) and 2 patients with cholangiocarcinoma (8.3%). The access routes of EUS-BD were choledochoduodenostomy which were conducted in 23 patients (95.8%) and hepaticogastrostomy in 1 patients (4.2%). Biliary stent were placed transluminally in 23 patients and trans-papillary in 1 patients. The technical and clinical success rate of stent placement, which is defined as the 50% decrease of bilirubin level one week after the procedure, were 79.1% (19) among patients with choledochoduodenostomy approach and 100% (1) in patient with hepaticogastrostomy approach. Four patients were unsuccessful to achieve biliary drainage. CONCLUSIONS: Among patients who underwent EUS-BD, there were no differences in age and gender, and tumor in the head of pancreas is the commonest diagnosis. EUS-BD is an effective and efficient technique of biliary drainage among patients with malignant biliary obstruction after failed ERCP. Conflict of Interest: None declared.



19.02.2017 POSTER AREA ENDOSCOPIC ULTRASOUND: ENDOSCOPY: EUS INTERVENTIONAL PANCREAS P395: CLINICAL IMPACT OF EUS TREATMENT OF WALLED OFF PANCREATIC NECROSIS WITH DEDICATED DEVICES: A RETROSPECTIVE ANALYSIS Ilaria Tarantino, Dario Ligresti, Luca Barresi, Gabriele Curcio, Antonino Granata, Mario Traina ISMETT - UPMC (Mediterranean Institute for Transplantation and Advanced Specialized Therapies, University of Pittsburgh Medical Center), Palermo, Italy

AIMS: Superiority of trans-gastric endoscopic necrosectomy over surgical necrosectomy was demonstrated. However, standard endoscopic techniques were associated with long procedural time and complications, stent migration and bleeding, pointing out the need of dedicated devices. The primary aim of this study was to evaluate the survival rate and clinical efficacy of EUS-guided drainage of infected Walled Off Pancreatic Necrosis (WOPN) with a new dedicated lumen apposing metal stent (LAMS) and subsequent Direct Endoscopic Necrosectomy (DEN). Secondary aims were to evaluate technical success, adverse events, procedure time, number of endoscopic procedures, and length of hospital stay. METHODS: Survival was evaluated at 1 and 3 months after the first procedure. Clinical success was evaluated as recovery from sepsis associated with disappearance of WOPN at CT scan after LAMS removal. All consecutive patients with infected WOPN who underwent LAMS placement and DEN between February 2014 and February 2016 were retrospectively reviewed. The novel device used in this study is a large-diameter biflanged FCSEMS directly advanced under EUS guidance into the cavity by using the electrocautery tip of the delivery system. After deployment of the LAMS, immediate DEN was performed with a standard gastroscope.

RESULTS: 19 patients (mean age 59.8 years, female 31.5 %), were included. LAMS placement and necrosectomy (technical success) was achieved in 18 (94.9%) patients. Mean procedure time was 42.9 minutes. Mean number of sessions was 3.9 (1–9). Clinical success was achieved in 15/18 (83.3 %) patients. Mean length of hospital stay was 19 days (3–43). Median follow up was 261 days (IQR 270). No adverse events occurred. A total of 3 patients died during the study period: the survival rate was 84.2% and 78.9% at 1 and 3 months after procedure. CONCLUSIONS: This study demonstrates excellent efficacy and safety of this approach with significant impact on survival. Conflict of Interest: None declared.


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P396: ENDOSCOPIC TREATMENT OF PAIN SYNDROME IN PANCREATIC CANCER Konstantin Ryabov, Maria Rudakova Municipal Clinical Hospital No 57, Oncology, Moscow, Russia

AIMS: To evaluate effectiveness of endoscopic methods of pain syndrome arresting in pancreatic cancer (PC) course. METHODS: There were 40 patients with pain syndrome (7–9 points by 10 points scale) due to regional cancer of the pancreatic head (26) and pancreatic body and tail (14) during 2013–2016 years. Ultrasound complex Olympus EU-NE1 and convex endoscope UST140 were used for endoscopic neurolysis. In two patients formation of puncture pancreaticodigestive anastomosis (in one patient - with duodenal bulb and in another - with stomach) was performed. Formation of anastomosis was performed under control of convex echo-endoscope. Puncture of the duct with the needle 19G and pancreaticography were performed. Positioning of plastic stent 8.5 Fr in the lumen of pancreatic duct along core wire on the delivery device was performed.

RESULTS: Effect of the procedure - decrease of pain level achieved in 100% patients. The best result was received in patients with pancreatic cancer of the body and tail - decrease from 7–9 points up to 0–1 point. In patients with pancreatic cancer of the head decrease of pain was up to 2–3 points. In two patients with significant pancreatic hypertension formation of pancreaticodigestive anastomosis was performed. Pain syndrome was arrested completely. CONCLUSIONS: We managed to obtain decrease of pain level due to performance of neurolysis. In the presence of pancreatic hypertension combination of neurolysis and drainage of pancreatic duct gives the best results. Conflict of Interest: None declared.

P397: FAT GLOBULES WITHIN ORGANIZED PANCREATIC FLUID COLLECTIONS ON CT SCAN IMPACT THE OUTCOMES OF NONSURGICAL DRAINAGE Ayesha Kamal, Atif Zaheer, Saowanee Ngamruengphong, Robert Moran, Yamile Chavez, Majidah Bukhari, Mouen Khashab, Vivek Kumbhari, Eboselume Akhuemonkhan, Venkata Akshintala, Anthony Kalloo, Vikesh Singh Johns Hopkins University, Baltimore, USA

AIMS: To assess whether the presence of fat globules in pancreatic fluid collections (PFCs) on computed tomography (CT) scan impacts the outcomes of non-surgical drainage. METHODS: Patients with an organized PFC as well as CT scan obtained at least 4 weeks after their episode of acute


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pancreatitis between 1/1993 and 1/2015 were identified using an administrative database.

type of stents used for drainage: double pigtail PS (group A), and FCSEMS (NAGITM) (group B).

RESULTS: 58 patients with 77 collections were identified with a mean age of 53.76 15.08 years.There were 22 (29%) PFCs that spontaneously resolved whereas 55 (61%) PFCs required drainage after a mean of 24.5 44.7 days from the time of PFC diagnosis. Fat globules were seen in 35 (45%) PFCs on CT with 21 PFCs drained endoscopically, 5 drained using both endoscopic and percutaneous approach and 2 drained percutaneously as compared to 42 (55%) PFCs with no fat on CT of which 12 were drained endoscopically, 14 were drained percutaneously and 1 was drained using both endoscopic and percutaneous drainage (P = 0.03). Technical success was achieved in all PFCs. Among the PFCs with fat globules, 12 were endoscopically drained using lumen-apposing metal stents (LAMS) and 8 using double pigtail plastic stents vs 6 and 4 in PFCs without fat globules, respectively (P = 0.001). There were 9 PFCs with fat globules that required reintervention as compared to 3 PFCs without fat (P = 0.024). PFCs containing fat globules resolved after mean time of 57.30 46.81 days as compared to PFCs without fat globules which resolved after 29 25.1 days (P = 0.003).

RESULTS: 21 patients were enrolled; group A (n = 13, 8M) and group B (n = 8, 4M). Mean diameter of PFC in group A and B were 10.3 and 9.5 cm, respectively. Location of PFC were mainly in body of the pancreas (n = 13). Nine patients had chronic pancreatitis. Number of patients with wall-off pancreatic necrosis (WON) in group A and B were 3/13 (23.1%) and 1/8 (12.5%) patients, respectively (P = 1.0). Technical success rate (TSR) was 100% in both groups. Clinical success rate (CSR) in group A and B were 8/13 (61.5%) and 7/8 (87.5%), respectively (P = 1.0). Causes of failed clinical success in 5 patients in group A were stent migration (n = 2) and inadequate drainage of WON (n = 3). In group B, a patient failed clinical success due to inappropriate position of the NAGI stent. However, if WON was excluded from both groups; CSR in group A and B were 8/10 (80%) and 6/7 (85.7%), respectively (P = 1.0).

CONCLUSIONS: In this current study, the PS tended to have lower CSR than the NAGI stent although it´s not significant. However, if target lesions were pseudocyst, the CSR between both groups was clearly comparable. Conflict of Interest: None declared.

CONCLUSIONS: Pancreatic Fluid Collections containing fat globules on CT scan more commonly required lumen-apposing metal stents, combined drainage modalities, multiple interventions, and had a significantly longer duration to resolution as compared to those without fat globules. Fat globules seen within PFCs on CT scan can help endoscopists with preprocedure planning, thereby avoiding requirement of MRI to differentiate PFCs into walled-off necrosis or pseudocyst. Conflict of Interest: None declared.

P399: NEW FULLY COVERED LARGE-BORE REMOVABLE METAL STENT - WITH ANTIMIGRATORY FLANGES FOR DRAINAGE OF PANCREATIC FLUID COLLECTIONS (PFC’S): RESULTS OF A SINGLE CENTER EXPERIENCE Nachiket Dubale1, Mahesh Mahadik1, Harshal Prabhakar Gadhikar1, Rajendra Pujari1, Jay Bapaye2, Amol Bapaye1 1

P398: PLASTIC VS ANCHORED FULLY-COVERED METAL STENTS (NAGITM) FOR EUS-GUIDED DRAINAGE OF PANCREATIC FLUID COLLECTION Prapimphan Aumpansub, Pradermchai Kongkam, Tanyaporn Chantarojanasiri, Wiriyaporn Ridtitid, Borndeb Angsuvajarakorn, Piyachai Orkoonsawat, Kasidit Norasettkul, Pinit Kullavanijaya, Rungsun Rerknimitr Chulalongkorn University and King Chulalongkorn Memorial Hospital, Department of Medicine, Bangkok, Thailand

Deenanath Mangeshkar Hospital, Shivanand Desai Center for Digestive Disorders, and 2Smt. Kashibai Navale Medical College, Pune, India

AIMS: Endoscopic transmural drainage (ETMD) of peripancreatic fluid collections (PFC) is an effective alternative to surgical drainage. Plastic stents pose problems of incomplete drainage and metal stents of migration. We present our data assesing efficacy and safety of a newly designed fully covered bi-flanged metal stent (BFMS) with anti-migratory flanges and with internal diameter of 14 mm (Hanaro, MI Tech, South Korea) for ETMD.

AIMS: Previously, plastic stents (PS) are commonly used for EUS-guided drainage of pancreatic fluid collection (EUS-PFC). Later on, a specially designed anchored fully-covered self expandable metal stents (FCSEMS: NAGITM) have been increasingly used. We aimed to compare efficacy and adverse events of PS vs the NAGITM stent in EUS-PFC.

METHODS: Retrospective analysis of prospectively collected

METHODS: From January 2009 to July 2016, medical records

RESULTS: 12 patients underwent EUS guided ETMD using this BFMS during five month period (July - October 2015), males =10. Mean age = 37 years (20–65). Nine pseudocysts (PPC’s), three walled off necrosis (WON). Technical and clinical success –100%. Direct endoscopic necrosectomy (DEN) was performed in 3

of all patients who had undergone EUS-PFC at King Chulalongkorn Memorial Hospital, Bangkok, Thailand were retrospectively reviewed. Patients were classified into 2 groups based on

data in a single center with adequate experience in EUS guided ETMD. Parameters assessed: technical and clinical success, feasibility of endoscopic necrosectomy / stent removal and adverse events. Suitable imaging was used to confirm PFC resolution. Stents removed within six weeks of placement.


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 (25%). No adverse events were observed. Mean duration of follow up -10 weeks (4–20). All stents could be removed.

CONCLUSIONS: The new specially designed antimigratory BFMS is safe and effective for drainage of PFC. Endoscopic necrosectomy can be carried out through the stent. Stent can be removed endoscopically at the end of the treatment period. No incidences of spontaneous stent migration or stent related tissue erosion were noted in this small series of patients. Conflict of Interest: None declared.


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P401: PROSPECTIVE EVALUATION OF EFFICACY AND SHORT TERM OUTCOMES OF EUS GUIDED DRAINAGE OF PANCREATIC FLUID COLLECTIONS WITH NOVEL LUMEN-APPOSING NAGI COVERED SELF EXPANDABLE METALLIC STENT B. V. N. Kumar, Rajesh Gupta, Sandeep Lakhtakia, Mohan Ramchandani, K. Rakesh, P. D. Jhahangeer, D. Nageshwar Reddy Asian Institute of Gastroenterology, Department of Medical Gastroenterology, Hyderabad, India

P400: FEASIBILITY AND EFFICACY OF THE NEWLY DESIGNED PLASTIC STENT FOR EUS-GUIDED PANCREATIC DUCT DRAINAGE SINGLE CENTER LARGE CASE SERIES EVALUATIONΔ Yukitoshi Matsunami, Atsushi Sofuni, Takayoshi Tsuchiya, Shujiro Tsuji, Kentaro Kamada, Reina Tanaka, Ryosuke Tonozuka, Mitsuyoshi Honjyo, Shuntaro Mukai, Mitsuru Fujita, Kenjiro Yamamoto, Yasutsugu Asai, Takao Itoi Tokyo Medical University, Gastroenterology and Hepatology, Tokyo, Japan

AIMS: Recently, EUS-guided pancreatic duct drainage (EUS-PD) has been advocated as an alternative for patients after failed ERCP. However, there are few dedicated devices for EUS-PD. Thus, we developed a new single pigtail plastic stent designed for EUS-guided interventions. The aim of this study is to retrospectively evaluate the feasibility and efficacy of the newly designed plastic stent for EUS-PD. METHODS: Twenty-seven patients (12 males and 15 females; age range, 26–93 years old; median, 59 years old) with acute recurrent pancreatitis due to main pancreatic duct (MPD) stricture or stenotic pancreatojejunostomy underwent EUS-PD using this new plastic stent. The procedure of EUS-PD in our institution is that firstly MPD is punctured transluminally with a 19-gauge or 22-gauge fine-needle under EUS guidance. The tract is dilated over a guidewire with a 6Fr electrocautery dilator. After tract dilation, new tapered tip and fourfold-flanged single pigtail plastic stent (total length: 20-cm, effective length: 15-cm, flanges: 4 with apertures, side holes: total 12 holes, distal straight site, 4 holes and pigtail site, 8 holes) is placed.

RESULTS: Technical and clinical success rate were both 100% (27/27). Self-limited abdominal pain was observed in 4 patients, mild pancreatitis in 1, bleeding in 1 which needed TAE for hemostasis. There was no stent migration case.

AIMS: We evaluated the safety and efficacy of a novel covered bi-flanged metal stent (BFMS) in draining PFCs. METHODS: Consecutive patients with symptomatic PFCs undergoing EUS guided drainage using the novel BFMS were included from 01 Dec 2014 to 30 Nov 2015. Patients were reassessed at the end of 01 week and at the end of 03 months for symptom improvement and reduction in size of collection. A naso-cystic catheter (NCT) and /or declogging of BFMS was performed in select patients. Subsequent Direct Endoscopic Necrosectomy (DEN) was performed through BFMS in patients with persistent symptoms.BFMS were removed between 4 to 8 weeks in asymptomatic patients after documenting radiological resolution of collection. The main outcome measures studied were clinical success and adverse events.

RESULTS: A total of 96 patients (median age of 33 years, range: 11–65, 85 males) with symptomatic PFCs underwent EUS guided transmural drainage with BFMS. Technical success was achieved in 95 patients (99%). Periprocedure adverse events occurred in 3 (3.2%) patients (bleeding in 2 & perforation in 1). Re-intervention was required in 9 (9.4%) patients for persistent or new onset symptoms. Eventually DEN was required in 7 (7.3%) patients. BFMS migrated in 16 (17 %) patients (3 internal, 13 external). One patient required surgery (1%). Overall, clinical success was achieved in 89 (98.9 %) patients with 90% clinical success in patients with pseudocyst and 98.75% in patients with WON. CONCLUSIONS: EUS guided drainage with novel BFMS is safe and effective in draining PFCs. This novel BFMS has shown to improve the clinical outcomes particularly in WON by permitting through the stent DEN and at the same time decreasing the number of re-interventions. Conflict of Interest: None declared.

CONCLUSIONS: The use of the newly dedicated plastic stent for EUS-PD is feasible and effective. Conflict of Interest: None declared.


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P402: “DISCONNECTED PANCREATIC DUCT SYNDROME” FOLLOWING EUS GUIDED CYSTOGASTRIC METAL STENTING: A PROSPECTIVE STUDY Partha Pal, Sundeep Lakhtakia, Jahangeer Basha, Rajesh Gupta, Mohan Ramachandani, Rakesh Kalapala, Zaheer Nabi, Jagdeesh Singh, Rao V. Guduru, Manu Tandan, D. Nageshwar Reddy Asian Institute of Gastroenterology, Gastroenterology, Hyderabad, India

AIMS: Limited data is available on occurrence of disconnected pancreatic duct syndrome (DPDS) in patients with pancreatic fluid collections (PFC) undergoing EUS guided drainage. Earlier studies have shown that a long-term plastic stent placement can reduce the recurrence rate. But, data was lacking on metal stents, which cannot be kept for longer period. We aim to evaluate the occurrence of DPDS after EUS guided drainage and recurrence of collection after metal stent removal. METHODS: Patients of Acute Pancreatitis with large symptomatic PFC who underwent EUS guided drainage using biflanged stent. (BFMS) (Nagi stent, Taewoong Medical Co Ltd, Korea) from Dec 2014 to May 2016 were included. Patients were followed at 4 to 8 weeks with magnetic resonance pancreaticogram (MRCP) to evaluate pancreatic ductal anatomy and an endoscopic retrograde pancreaticography (ERP) before removal of the BFMS to confirm MRCP finding and further management.

RESULTS: A total of 121 patients underwent EUS guided drainage with placement of FCSEMS. Total 112 patients underwent MRCP and among them 97 patients underwent ERCP of which 94 patients had successful PD cannulation. ERCP documented DPDS was seen in 72 patients, normal PD gram seen in 18 patients and leak in 4 patients. 3 patients had pancreas divisum. Among 72 patients with DPDS, cut off was seen in head, genu, body and tail in 10, 35, 14 and 13 patients respectively. Total 10 patients had recurrence, of which 7 patients (70%) had small asymptomatic cyst and 3 patients (30%) had large, symptomatic (>5 cm) collection which required cysto-gastric plastic stent. Rest 7 patients are under follow up. CONCLUSIONS: The occurrence of DPDS is higher than expected after cysto-gastric drainage. Most common location of DPDS was genu. Contrary to previous reports, around 11% patients had recurrence of collection but only 3% had symptomatic recurrence requiring treatment. Conflict of Interest: None declared.


P403V: SPONTANEOUS MIGRATION OF FCSEMS INTO COLON: AN UNUSUAL COMPLICATION OF EUS GUIDED CYSTO-GASTRIC DRAINAGE OF PANCREATIC FLUID COLLECTIONS Partha Pal, Sundeep Lakhtakia, Jahangeer Basha, Rajesh Gupta, Mohan Ramachandani, Rakesh Kalapala, Zaheer Nabi, P. Manohar Reddy, Hrushikesh Chaudhari, D. Nageshwar Reddy Asian Institute of Gastroenterology, Gastroenterology, Hyderabad, India

AIMS: Endoscopic ultrasound (EUS) guided cysto- gastric drainage using fully covered self-expandable stents (FCSEMSs) has emerged as an effective treatment modality for pancreatic fluid collections (PFC). Spontaneous migration of tubular stents hindered PFC management in earlier studies. The Nagi stent (Nagi; Taewoong Medical, Gyeonggi-do, South Korea) is a novel lumen-apposing, bi-flanged SEMS for drainage of PFCs which has flared ends to prevent migration. We present here a case of spontaneous migration of FCSEMS into colon after EUS guided cystogastric drainage. METHODS: We described the case of a 14-years-old boy with idiopathic recurrent acute pancreatitis who presented with a large symptomatic walled off pancreatic necrosis (WOPN) in body and tail of pancreas (137 x 114 mm size on EUS). Using a therapeutic linear echo-endoscope (UCT-180; Olympus Ltd, Tokyo, Japan), a fully covered 16 mm diameter biflanged SEMS was placed. Computed tomography (CT) after 48 h showed significant reduction (75%) in size of the collection. He was advised to follow up after 4 weeks for stent removal.

RESULTS: However, two weeks later, he presented with pain abdomen, vomiting and low grade fever. CT abdomen showed 4.5 x 1 cm residual collection and FCSEMS in transverse colon. Colonoscopy showed an impacted cysto-gastric SEMS in descending colon which was removed with biopsy forceps by holding the drawstring attachment located at the gastric end of the SEMS (Video 1). He improved symptomatically and discharged. CONCLUSIONS: In previous studies, most spontaneous migrations of FCSEMS were into the stomach and passed by the patient. Rapid decompression of cyst with FCSEMS is important factor in spontaneous migration that overcomes the flared ends. This case shows that FCSEMS after EUS guided drainage for pancreatic fluid collection can spontaneously migrate distally and can cause colonic impaction which is best managed by colonoscopic removal of the stent. Conflict of Interest: None declared.



P404: MICROBIOLOGIC ANALYSIS OF PANCREATIC FLUID COLLECTIONS DURING EUS GUIDED DRAINAGE: A LARGE EXPERIENCE FROM A SINGLE TERTIARY CARE GI CENTER Vaibhav Ajmere, Jahangeer Basha, Sundeep Lakhtakia, Rajesh Gupta, Mohan Ramachandani, Rakesh Kalapala, Zaheer Nabi, Partha Pal, Anuradha Kancharla, D. Nageshwar Reddy Asian Institute of Gastroenterology, Gastroenterology, Hyderabad, India

AIMS: Mortality dramatically increases if peri-pancreatic fluid collections (PFC) become infected. The differentiation between sterile and infected PPFCs remains difficult. If infection is suspected, empiric antibiotic therapy with broad-spectrum antibiotic like carbapenems has been suggested. However, empiric non-target based therapy carries risk of selecting antibiotic resistant Strains and treatment failure. The present study is designed to evaluate the value of microbiologic analysis of aspirates from PFCs and impact on the antibiotic management in study. METHODS: Consecutive patients of Acute Pancreatitis with large symptomatic PFC having varied amount of solid debris were included during the study period from January 2016 to August 2016. During the EUS guided drainage procedure the first aspirated sample from PFC on puncture with 19G needle was sent and immediately inoculated into blood agar and chromogenic agar (urichrome) and incubated for 48 h, for any suspicion of fungus were further incubated for 24 h. The identification and sensitivity of organisms grown was done on VITEK- 2 system (Automated system). Antibiotics were modified according to symptoms and antibiotic sensitivity reports.

RESULTS: 63 patients (males 85.71%) underwent EUS guided drainage of PFC. Colonization of PFCs was found in 31 patients (49.1%) of PFC cultures. The presence of necrosis was the strong risk factor for colonization seen in 91.49%. While signs of systemic inflammations like fever and leukocytosis were seen in only 23.81% & 27.27% of patients. Most common organism cultured was E-coli (14.81%) and most organisms were susceptible to Tazobactum (92%). Nearly half of the organisms were resistant to commonly used antibiotics like cephalosporins, fluoroquinolones & carbapenems.

CONCLUSIONS: The microbiologic colonization of PPFCs in patients with pancreatitis is common. Only the direct microbiologic analysis of PPFCs, is useful to optimize an effective antibiotic therapy in patients with pancreatitis. Conflict of Interest: None declared.


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P405: SUSTAINED BENEFICIAL EFFECT OF EUS GUIDED RFA IN MANAGEMENT OF PANCREATIC INSULINOMA Sundeep Lakhtakia, Rajesh Gupta, Jahangeer Basha, Mohan Ramchandani, Rakesh Kalpala, D. Nageshwar Reddy Asian Institute of Gastroenterology, Gastroenterology, Hyderabad, India

AIMS: Background: Insulinomas are most common functional pancreatic neuroendocrine tumors. Surgical removal is the standard of care. However, patients unfit for surgery require alternative non-surgical method to reduce symptoms. EUS has been used to ablate pancreatic insulinoma using EUS guided RFA with beneficial early results. Aim: To evaluate sustained effect of EUS guided RFA used to ablate pancreatic insulinoma. METHODS: We have followed carefully all patients with clinical and biochemical follow up, initially every 3 months for first year and later at half yearly interval. The imaging was assessed at one-year interval.

RESULTS: We earlier reported 3 patients with a symptomatic pancreatic insulinoma who underwent a single session of EUSRFA each, by using a special internally cooled needle electrode. All patients had rapid relief of symptoms with biochemical improvement. These patients have remained symptom free at 24 to 30 months of follow-up, with no recurrence of hypoglycemic symptoms. Also the biochemical profiles (Fasting blood sugar, fasting serum insulin and fasting serum C-peptide) are within normal range. In one patient, the lesion is not visualized on EUS and CECT scan. CONCLUSIONS: EUS-RFA can be considered in patients with symptomatic pancreatic insulinoma with early benefit and sustained clinical effect. Conflict of Interest: None declared.

P406V: EUS-GUIDED RENDEZVOUS PANCREATIC DUCT DRAINAGE IN RELATIVELY NON-DILATED SYSTEM IN CHRONIC CALCIFIC PANCREATITIS Amol Bapaye, Nachiket Dubale, Mahesh Mahadik, Rahul Lokhande, Tarun Bharadwaj, Rajendra Pujari, Siva Sankar Reddy Gangireddy, Suhas Date Deenanath Mangeshkar Hospital, Shivanand Desai Center for Digestive Disorders, Pune, India

AIMS: ERCP and pancreatic duct (PD) stenting is an accepted treatment modality for relieving pain in patients with obstructive chronic pancreatitis and ductal hypertension. In failed ERCP cases, EUS guided rendezvous (EUS-RV) has been described when main pancreatic duct (MPD) is dilated. EUS-RV is rarely


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reported for non-dilated ducts, possibly due to technical difficulty. Demonstration of modified EUS-RV technique for PD cannulation in a non-dilated duct.

METHODS: 13 years old female, diagnosed chronic calcific pancreatitis presented with severe recurrent refractory abdominal and back pain. Magnetic resonance cholangio-pancreaticography (MRCP) revealed MPD stricture in neck region with 3 mm proximal duct. At ERCP, guidewire could not be negotiated across stricture despite multiple attempts. Decision of EUS-RV was taken. Linear EUS showed 2 mm MPD. EUS guided MPD puncture was performed through posterior gastric wall using 25 G needle under color Doppler control. MPD was distended by injecting contrast. Pancreatogram revealed mildly dilated and tortuous MPD with stricture in head region. Distended MPD was then punctured using 19G needle and 0.032-inch guide wire was advanced through MPD and across papilla. After exchanging for a side-viewing endoscope, alongside-the-wire deep MPD cannulation was achieved. After pancreatic sphincterotomy, a single pigtal 5Fr. stent was deployed.

RESULTS: Post procedure course was uneventful. At four weeks follow up, patient had complete resolution of pain.

CONCLUSIONS: EUS-RV for non-dilated MPD is feasible and safe. The described technique may salvage otherwise patients who are otherwise difficult to treat candidates. Conflict of Interest: None declared.

P407: ENDOSCOPIC REINTERVENTION USING A “STEP-UP APPROACH” AFTER EUS GUIDED DRAINAGE OF WON WITH BI-FLANGED METAL STENT Sundeep Lakhtakia, Jahangeer Basha, Partha Pal, Rajesh Gupta, Bvn Kumar, Mohan Ramachandani, Rakesh Kalapala, Zaheer Nabi, Jagdeesh Singh, Rao V. Guduru, D. Nageshwar Reddy Asian Institute of Gastroenterology, Gastroenterology, Hyderabad, India

AIMS: Earlier studies report a striking heterogeneity in the re-intervention rate with metal stent (4–79%) due to inclusion of both pseudocyst (PC) and walled off necrosis (WON). We aimed to evaluate the need for reintervention in WON after EUS guided drainage with bi-flanged metal stent (BFMS). METHODS: Consecutive patients with symptomatic WON undergoing EUS guided drainage using BFMSwere included from January 2013 to December2015. Patients were reassessed at 48–72 h for symptom improvement and reduction in size of collection. The endoscopic interventions were approached in a step-up manner to manage patients who did not have expected clinical improvement after index drainage of WON with BFMS. Declogging of blocked lumen

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 of BFMS was the first step. Second step involved a naso-cystic catheter (NCT) placement through BFMS followed by intermittent irrigation. Third step involved direct endoscopic necrosectomy (DEN), which was performed through BFMS in patients with persistent symptoms.

RESULTS: A total of 205 patients (mean age 34.8 12.5 years, 181 males) underwent EUS guided drainage with BFMS.WON resolved with BFMS in 158 (74.6%). Endoscopic re-intervention, required in 49 (23.9%) patients, for persistent or new onset symptoms was approached in a step-up manner. At first, de-clogging of BFMS alone succeeded in 10 out of 21. Second step of nasocystic placement through BFMS followed by irrigation with saline and hydrogen peroxide improved 16 out of in 39. At final step, DEN improved outcome in 19 out of 23. Twelve required one session, 6 needed 2 sessions, 4 needed 3 sessions, and 1 needed 4 sessions of DEN.Four patients were symptomatic even after DEN. Two of them required surgical necrosectomy and the other 2 underwent percutaneous drainage. CONCLUSIONS: EUS guided drainage with BFMS achieves high incremental success rate with step-up approach with only a quarter of patients requiring reintervention and 10% requiring DEN. Conflict of Interest: None declared.

P408: DIFFICULTY IN DELAYED STENT REMOVAL AFTER ENDOSCOPIC ULTRASOUND GUIDED DRAINAGE OF WALLED OFF NECROSIS WITH BIFLANGED METAL STENT Sundeep Lakhtakia, Jahangeer Basha, Partha Pal, Rajesh Gupta, Mohan Ramachandani, Rakesh Kalapala, Bvn Kumar, Zaheer Nabi, Rao V. Guduru, Manu Tandan, D. Nageshwar Reddy Asian Institute of Gastroenterology, Gastroenterology, Hyderabad, India

AIMS: EUS guided drainage using metal stents has recently become popular than plastic stents for the treatment of pancreatic fluid collections (PFC) including WON. But, compared to plastic stents, metal stents cannot be kept for longer duration as they get epithelialized causing difficulty in removal due to loss of silicone membrane accompanied with tissue embedment. We aimed to evaluate the difficulty in removal of BFMS after successful resolution of WON in patients who reported late (>3 months). METHODS: We retrospectively evaluated 205 consecutive patients with symptomatic WON who underwent EUS guided drainage using BFMS over a period of 3 years. After reassessment between 48–72 h, endoscopic re-interventions were done in non-responders in a stepwise manner. All the patients were followed for 4–8 weeks, when the BFMS were removed after documenting resolution of WON on trans-abdominal ultrasound imaging. Difficulty in stent removal


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 was noted for patients who reported late (>3 months to 1 year).

RESULTS: Most of the patients were followed up at 4–8 weeks after the procedure. BFMS spontaneously migrated externally after complete resolution (clinical & radiological) of WON in 15 patients. All the patients (162, 79%) who reported between 4– 8 weeks had easy stent removal. Delayed removal of BFMS was performed in 21 patients (between 3–12 months after placement) who reported late. Removal was uncomplicated in 12 patients. Nine had complicated removal requiring either argon plasma coagulation (APC) of the gastric wall around the BFMS with or without piecemeal removal. Finally, all the stents could be removed successfully.


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RESULTS: Post drainage patient was significantly improved symptomatically. Repeat CT scans showed significant reduction in size of cyst. 48 h later a recheck sigmoidoscopy was done, which showed BFMS well in position draining pus. BFMS was removed after 2 weeks. CONCLUSIONS: Infected pancreatic collections in pelvis close to colon can be safely drained via EUS guided fully covered BFMS safely and effectively without need for surgery or percutaneous drainage. Fully covered BFMS is advantageous compared to plastic stent in the setting of large pelvic collections with significant debris. Conflict of Interest: None declared.

CONCLUSIONS: Delayed removal of BFMS (>3 months) is associated with higher level of difficulty in stent removal. Although difficult in some, stent can be removed safely in most of the cases even after significant delay in stent removal. Conflict of Interest: None declared.

P410: ENDOSCOPIC ULTRASOUND GUIDED PANCREATIC NECROSECTOMY USING STEP-UP APPROACH FOR WALLED FOR PANCREATIC NECROSIS: A TERTIARY CENTRE, PROSPECTIVE OPEN LABEL STUDY

P409V: ENDOSCOPIC ULTRASOUND GUIDED DRAINAGE OF INFECTED PANCREATIC COLLECTION IN PELVIS USING BIFLANGED COVERED METAL STENT

Nisharg Patel, Mahesh Gupta, Sumit Bhatia, Gaurav Patil, Randhir Sud, Rajesh Puri

Mahiboob Najbuddin Sayyed, Sundeep Lakhtakia, Partha Pal, Jahangeer Basha, Mohan Ramachandani, D. Nageshwar Reddy Asian Institute of Gastroenterology, Gastroenterology, Hyderabad, India

AIMS: Endoscopic ultrasound (EUS) guided drainage procedure has been demonstrated to be an efficient alternative to ultrasound (USG) and computed tomography (CT) guided procedures in draining pelvic collections. Most of the published studies report drainage using plastic stents. Plastic stents are prone to get occluded easily if put in a large collection with significant debris. To overcome this limitation, we placed a fully covered biflanged covered metal stent (BFMS) for EUS guided drainage of infected pancreatic collection with significant debris in pelvis. METHODS: A 24 year old female with acute pancreatitisand multiple intra- abdominal infected pancreatic fluid collections presented to us. She had undergonepercutaneous drainage for left sub-diaphragmatic and left peri-hepatic collections with subsequent drain removal. Few days later she developed fever with chills and lower abdominal pain.Contrast enhanced CTof pelvis confirmed large pelvic collection extending into rectouterine pouch measuring15 cm x 8 cm. Trans-rectal EUS showed large well defined perirectal cystic lesion with thick echogenic fluid and significant dependent debris. Sigmoidoscopy showed large bulge in anterior rectal wall. She was put on intravenous broad spectrum antibiotics and underwent trans-rectal EUS guided fully covered BFMS after proper colon preparation.

Medanta - The Medicity, Gurgaon, India

AIMS: To investigate efficacy of endoscopic step-up approach for walled of pancreatic necrosis (WOPN). METHODS: This was a prospective open label study. 64 Patients with symptomatic walled off necrosis of pancreas (pain, fever, features of gastric outlet obstruction, biliary obstruction) who were amenable to endoscopic drainage were allocated to EUS guided drainage by fully covered self expanding stent. Those patient who continue to have symptoms after 48 h were subjected to endoscopic necrosectomy by lavage with 1–2 litres of a solution containing, 3 % hydrogen peroxide (1:20 dilution). For those patient who still did not respond, imaging was done to look for the adequacy of the drainage. Incase of persistence of collection either repeat necrosectomy or percutaneous drainage (PCD) was done. Primary endpoints were completion of drainage with improvement in symptoms or major complications. Secondary endpoints were minor complications, hospital stay & number of necrosectomy sessions required. These patients were prospectively followed over a period of 6 months.

RESULTS: Out of the 64 patients, Primary endpoint occurred with FCSEMS alone in 18 (28.1%), FCSEMS with necrosectomy 40 (62.5%), FCSEMS with PCD 5 (7.8%) patients, 1 (1.5%) patient required salvage surgery. On subgroup analysis it was found that patients with more than 40% necrosis were likely to need necrosectomy as compared to FCSEMS alone (32 (80%) vs 2 (5%) P value < 0.01). Mean necrosectomy sessions required were 3.2. Major complications that occurred were life threatening bleeding in 3 (4.6%) all of which were managed by radiological intervention. Minor complications, non life threatening bleeding in 3 (4.6%), stent migration in 2 (3.1%). Average hospital stay was 4.8 days.


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CONCLUSIONS: Endoscopic necrosectomy using step-up approach is an very efficacious and safe. Conflict of Interest: None declared.

P412: EUS-GUIDED PERIRECTAL ABSCESS DRAINAGE WITHOUT DRAINAGE CATHETER: A CASE SERIES Eun Kwang Choi1, Ji Hyun Kim2 1

ENDOSCOPIC ULTRASOUND: ENDOSCOPY: EUS INTERVENTIONAL VASCULAR & OTHER P411: ENDOSCOPIC ULTRASONOGRAPHY-GUIDED PLACEMENT OF A TRANSHEPATIC PORTAL VEIN STENT IN A LIVE PORCINE MODEL Tae Young Park1, Dong Wan Seo2, Hyeon-Ji Kang3, Min Keun Cho2, Tae Jun Song2, Do Hyun Park2, Sang Soo Lee2, Sung Koo Lee2, Myung-Hwan Kim2 1

Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Internal Medicine, Chuncheon, 2Asan Medical Center, University of Ulsan College of Medicine, Division of Gastroenterology, Seoul, and 3Asan Institute for Life Sciences, University of Ulsan College of Medicine, Division of Gastroenterology, Seoul, Korea

AIMS: Percutaneous portal vein (PV) stent placement is used to manage PV occlusion or stenosis caused by malignancy. The use of endoscopic ultrasonography (EUS) has expanded to include vascular interventions. The aim of this study was to examine the technical feasibility and safety of EUS-guided transhepatic PV stent placement in a live porcine model. METHODS: EUS-guided transhepatic PV stent placement was performed in six male mini pigs under general anesthesia using forward-viewing echoendoscope. Under EUS guidance, the left intrahepatic PV was punctured with a 19-gauge fine needle aspiration (FNA) needle and a 0.025 inch guide wire inserted through the needle and into the main PV. The FNA needle was then withdrawn and a needle-knife inserted to dilate the tract. Under EUS and fluoroscopic guidance, a non-covered metal stent was inserted over the guide wire and released into the main PV.

RESULTS: A PV stent was placed successfully in all six pigs with no technical problems or complications. The patency of the stent in the main PV was confirmed using color Doppler EUS and transhepatic portal venography. Necropsy of the first three animals revealed no evidence of bleeding and damage to intraabdominal organs or vessels. No complications occurred in the remaining three animals during the 8 week observation period.

Jeju National University Hospital, Internal Medicine, Jeju-Do, and 2Busan Paik Hospital, Internal Medicine, Busan, Korea

AIMS: A perirectal abscess is relatively common disease entity that occurs as a postsurgical complication and as a result of various medical diseases. Endoscopic ultrasound (EUS) guided drainage was recently described as a promising alternative treatment. Previous reports have recommended placement of a drainage catheter through the anus for irrigation, which is inconvenient to the patient and carries a risk of accidental dislodgement. METHODS: We report a retrospective analysis of prospectively collected cases of patients who underwent EUS-guided drainage of perirectal abscess in two academic centers.

RESULTS: Four patients underwent EUS-guided drainage of perirectal abscesses. The median patient age was 34 years (range, 17–48), and two of the patients were male, while two were female. The median abscess size was 57 mm x 37 mm (range, 40 mm x 32 mm–83 mm x 60 mm). The perirectal abscess was visualized by using a curvilinear array echoendoscope (GF-UCT240; Olympus Medical Systems Co., Tokyo, Japan) and then punctured with a 19 gauge needle (Echotip ultra, Wilson-Cook Medical Inc., Winston-Salem, NC, USA). The dilation of the track between the rectum and the abscess cavity was made either graded dilation or introducing a 6F cystotome (Endo-Flex, Voerde, Germany) followed by the placement of one or two 7F double pigtail plastic stents (Cook Ireland Ltd., Limerick, Ireland). The procedure performed without any complications in all four patients. A follow-up CT scan obtained 7 to 14 days after procedure showed a complete resolution of the abscess in all patients. All the stents were retrieved successfully. There was no evidence of abscess recurrence during a median follow-up of 22 months (range, 5–48 months). CONCLUSIONS: EUS-guided transrectal stent placement without a drainage catheter was a technically easier, feasible and more convenient method. Prospective multicenter trials are required to validate the technical efficacy and safety of EUSguided stent placement without drainage catheter. Conflict of Interest: None declared.

CONCLUSIONS: EUS-guided transhepatic PV stent placement can be both technically feasible and safe in a live animal model. Conflict of Interest: None declared.



P413: LONG-TERM RESULTS OF ENDOSCOPIC ULTRASOUND-GUIDED CELIAC PLEXUS NEUROLYSIS Shinpei Doi, Ichiro Yasuda, Katsunori Sekine, Takayuki Tsujikawa, Masatoshi Mabuchi Teikyo University School of Medicine University Mizonokuchi Hospital, Department of Gastroenterology, Kawasaki, Japan

AIMS: To evaluate the long-term outcomes following Endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN). METHODS: We retrospectively reviewed patients who underwent EUS-CPN for alleviating pancreatic cancer-related pain between July 2003 and July 2012. The EUS-CPN described in the present study included both conventional EUS-CPN as well as EUS-celiac ganglia neurolysis (EUS- CGN). Pain was evaluated using the visual analog scale (VAS), and the initial evaluation was performed 7 days after procedures. Patients who exhibited a reduction in the VAS score to ≤3 were considered to show an effective response, whereas those who exhibited a reduction in the VAS score to ≤1 were considered to show a complete response. Univariate and multivariate analyses of the prognostic factors associated with the long-term effects of EUS-CPN until death were performed.

RESULTS: We evaluated 133 patients who underwent EUSCPN (EUS-CPN, 73 patients; EUS-CGN, 44 patients; both EUS-CPN and EUS-CGN, 16 patients) for pancreatic cancer-related pain. The effective response and complete response rate at the initial evaluation was 69% and 36%, respectively. The median (95% CI) duration of the effect was 61.0 (36.6–85.3) days. We found that the statistically significant prognostic factors of the long-term effect of EUS-CPN until death included a reduction in the VAS score by ≥4 at the initial evaluation, complete pain relief (VAS score of ≤1 at the initial evaluation), bilateral distribution of ethanol, and relatively short duration of pain prior to EUS-CPN (≤120 days); the hazard ratio (95% CI) of these factors were 2.0 (1.2–3.2), 1.9 (1.2–3.1), 2.8 (1.8–4.4), and 2.8 (1.7–4.5), respectively. CONCLUSIONS: Our findings indicate that the treatment effect of EUS-CPN may last longer in patients who exhibited a better response at the initial evaluation. Conflict of Interest: None declared.

P414: EUS GUIDED COILING IN REFRACTORY POSTCYANOACRYLATE GASTRIC VARICEAL BLEED Roy J. Mukkada, Antony Rajesh, Chooracken J. Mathew, V. J. Francis, A. P. Chettupuzha, P. G. Mathew, C. P. Shelley, Abraham Koshy VPS Lakeshore Hospital, Gastroenterology, Kochi, India

AIMS: The aim was to compare EUS guided coiling vis a vis cyanoacrylate injection in gastric variceal re-bleed.


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METHODS: A retrospective analysis of a prospectively maintained database was performed. Cirrhotic patients with gastroesophageal variceal bleed who had undergone cyanoacrylate injection and presenting with rebleed were included. 37 patients who re-bled after cyanoacrylate injection had endocoiling of varices were included. 44 comparison patients had only cyanoacrylate injection and was followed up for 12 months. Endocoiling was done under endosonographic guidance. A single coil was placed in 10, two coils in each of 21 patients, 3 coils in four, 4 coils in one and 6 coils in one patient. In addition, cyanoacrylate glue injection was given in 6 patients. Five patients had repeat endocoiling one month later. Re-bleed and mortality were assessed.

RESULTS: In Endocoiling group none of the patients re-bled during the follow-up of 15 to 365 days. One patient died two months after the procedure due to spontaneous bacterial peritonitis. In cyanoacrylate group 21/44 (48%) re-bled during follow-up of 45 to 365 days. 2/44 (2%) patients died in the group. Kaplan Meir Analysis showed statistically significant difference with respect to the probability of rebleed. (P = 0.04). CONCLUSIONS: EUS guided coiling for the obliteration of gastric varices is effective for post-cyanoacrylate gastric variceal re-bleed. Conflict of Interest: None declared.

P415: UTILITY OF ENDOSCOPIC ULTRASOUND IN PRE AND POST CYANOACRYLATE INJECTION OF GASTRIC VARICES Raiza Geires Bondoc, Evan Ong Metropolitan Medical Center, Manila, Philippines

AIMS: Acute gastric variceal bleeding is a life-threatening emergency and remains the most severe complication of liver cirrhosis and portal hypertension. EUS has a higher sensitivity for the detection and diagnosis of small gastric varices that may be mistaken as enlarged gastric folds. It also provides knowledge on therapeutic efficacy by confirming complete obturation after glue injection, provides assessment and prediction of variceal recurrence and for assessment of portal hemodynamics. METHODS: A 64-year old diabetic female came in due to melena. Initial gastroscopy revealed a tiny esophageal varix and a prominent fold at the cardia. No therapeutic interventions were done. Three months after, there was recurrence of melena. Repeat gastroscopy showed the previously prominent fold as a large varix for which injection with 1 cc of undiluted histoacryl was done. Six months after, melena recurred. An endoscopic ultrasound was done revealing hypoechoic and serpiginous structures with Doppler signal at the area of the GE junction. Injection of 0.5 cc of undiluted histoacryl was done.

RESULTS: Post enbucrylation EUS showed marked diminution of the vascular echoes. At present, no recurrence of bleeding eight months post obliteration.


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CONCLUSIONS: Endoscopic ultrasound has the ability to identify the presence of gastric varices when endoscopic evaluation is uncertain. Moreover, it can be used to evaluate the efficacy of variceal glue injection as well as the possibility for monitoring the degree of vascularity. Conflict of Interest: None declared.

P416V: HYBRID APPROACH FOR GASTRIC FUNDAL VARICES: A NEW TREATMENT Vikas Singla, Ravi Daswani, Anil Arora, Ashish Kumar, Praveen Sharma, Naresh Bansal Sir Ganga Ram Hopsital, Gastroenterology, New Delhi, India

AIMS: Background: Standard of care for gastric varix is endoscopic glue injection, which is asscoiated with risk of embolization. EUS guided coiling and glue injection has been proposed for the management of fundal varices. Because of the short polymerization time of the glue, there is high risk of clogging of the needle during the procedure making EUS guided glue injection difficult. We opted a new hybrid technique for the treatment of fundal varices, where EUS guided coiling was followed by glue injection with the forward viewing endoscope. Aim: To report the initial experience with hybrid technique in patients with gastric varices.

METHODS: Under EUS guidance, varices in the submucosal layer were localized and direct puncture with 19 G needle was performed. After the puncture coils were deployed with the help of stylet. The size of the coil was more than 25% of diameter of the varix. Coiling was done till the obliteration of varix and maximum of 5 coils were used. EUS was repeated the next day, and if the residual flow meaured >5 mm indiameter, glue was injected with forward viewing endoscope in retroflex position.

RESULTS: We performed EUS guided coil placement in four cases (3 males, 1 female) with median CTP score 9 1. Mean varix size was 2.8 mm (0.8 cms), active bleed was present in one case. No of coils deployed were 2.3, 3.5. 3 patients had complete oblitrartion of varices after coling only, one patient had persisitent flow after coiling, and glue was injected next day. None of the patient had rebleed in next 28 days.


P417V: OUTCOME OF EUS GUIDED GASTROJEJUNOSTOMY USING NAGI STENT Sudipta Dhar Chowdhury, Reuben Thomas Kurien, A. Bharath Christian Medical College, Gastroenterology, Vellore, India

AIMS: Follow up of EUS guided gastrojejunostomy using NAGI stent for relief of afferent loop obstruction. METHODS: A 27 year old male had presented to our hospital with cholangitis, sepsis and septic shock. He had undergone a Roux en Y hepaticojejunostomy and gastrojejunostomy a year ago for suspected ampulllary neoplasm a year ago. CECT showed features of afferent loop obstruction. We did an EUS guided gastrojejunostomy for relief of the afferent loop obstruction using a lumen apposing metal stent (LAMS). The dilated afferent limb was connected to the stomach using LAMS (Nagi stent) under EUS guidance. Following the stent placement the patient was discharged. The patient was followed up after four months of LAMS placement.

RESULTS: At four months the patient had gained 5 kgs of weight and did not have any further cholangitis episodes in the intervening period. He underwent an exploratory laparotomy to assess the level and nature of afferent loop obstruction. Intraoperative the Nagi stent was seen to have firmly anastomosed the stomach and afferent limb of hepatico-jejunostomy. The afferent limb was found to be encased distally by an inflammatory mass arising from the head of pancreas. CONCLUSIONS: EUS guided gastrojejunostomy using LAMS appears to be a safe procedure producing durable anastomosis between stomach and jejunum. Conflict of Interest: None declared.

P418: EUS-GUIDED THERAPY IN THE MANAGEMENT OF GASTRIC FUNDAL AND DUODENAL VARICES Shibi Mathew, Prakash Zacharias, Mathew Philip, John Mathews, Prashanth Menon, Maya Peethambaran, Aby Somu, Philip Augustine PVS Institute of Digestive Diseases, Medical Gastroenterology, Kochi, India

CONCLUSIONS: We found novel hybrid technique of coiling and glue injection of gastric varices with echoendoscope and forward viewing scope respectivley safe and feasible in a small cohort of patients. Conflict of Interest: None declared.

AIMS: Gastric fundal varices and duodenal varices are a cause of fatal variceal hemorrhage. Aim of this study was to analyse the safety and outcome of EUS guided therapy in the management of gastric fundal and duodenal variceal bleeding. METHODS: Retrospective analysis of patients with upper GI bleed due to gastric fundal and duodenal varices who were managed in our center with EUS guided therapy. Study period was 24 months with follow up till date.

RESULTS: 20 patients who underwent EUS guided variceal therapy were analysed. Mean age was 52.1 years. Ethanol related cirrhosis was the most common etiology (13 patients;


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 65%) followed by cryptogenic cirrhosis in 5 (25%). 16 cases had gastric fundal varices (GOV2 in 14 and IGV1 in 2) while four had duodenal varices. Most patients had large varices (70%). Eight patients presented with recurrence of bleed after endoscopic intervention done elsewhere, while other cases presented with fresh bleeding episode. A combined therapy of EUS guided intravariceal glue injection and coil insertion was done in 8 patients, while in the remaining patients, only EUS guided glue injection was done. On repeat evaluation, five patients (25%) had non-obliteration of the varices which needed a repeat EUS guided intervention. In the initial follow up period of 2 weeks, no one had any procedure related complications and only one had recurrence of bleed which was due to esophageal post variceal banding ulcers. 17 patients (85%) are under follow up till date, with a median follow up duration of 140 days. None had recurrence of bleed.

CONCLUSIONS: EUS guided therapy is a highly effective treatment modality for managing our group of patients with gastric fundal and duodenal varices. Conflict of Interest: None declared.

ENDOSCOPIC ULTRASOUND: ENDOSCOPY: EUS NEW TECHNOLOGY P419: ENDOSCOPIC ULTRASONOGRAPHY-GUIDED INTRAHEPATIC PORTAL VEIN EMBOLIZATION IN A ANIMAL MODEL


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was evaluated by color Doppler EUS. After 1 week observation period, necropsy was performed.

RESULTS: Embolization coil was placed in the selected intrahepatic PV successfully in all seven animals, and histoacryl injection was successful in six of them. In one case, histoacryl injection was failed due to FNA needle deflection. After embolization coil insertion and histoacryl injection, the disappearance of blood flow in the treated intrahepatic PV was confirmed by color Doppler EUS. There was no sign or symptom of peritonitis and bleeding in all five animals during 1 week observation period. Necropsy revealed no evidence of damage to the treated intrahepatic PV and intra-abdominal organs. CONCLUSIONS: EUS-guided intrahepatic PVE can be both technically feasible and initially safe in a live porcine model. Further animal studies are needed to demonstrate the efficacy and long-term safety of this challenging intervention. Conflict of Interest: None declared.

P420: STUDY OF ENDOSCOPIC ULTRASOUND ELASTOGRAPHY FOR DIFFERENTIATING BENIGN AND MALIGNANT SOLID PANCREASTIC MASS Pallav Parikh1, Sarojini Parameswaran1, Piraman Piramanayagam1, K.R. Palaniswamy1, Ramakrishnan Balasubramaniam2, A.T. Mohan1, Usha Srinivas1, Ubal Dhus1, M. Hariharan1, M.S. Revathy1, V.P. Seshadri1, Preethi Mahalingam1, Satish Nayak1, Shankar Jhanwar1

Tae Young Park1, Dong Wan Seo2, Hyeon-Ji Kang3, Dongwook Oh2, Tae Jun Song2, Do Hyun Park2, Sang Soo Lee2, Sung Koo Lee2, Myung-Hwan Kim2

1 Apollo Hospitals, Medical Gastroenterology, and 2Apollo Hospitals, Biostatistics, Chennai, India

1 Chuncheon Sacred Heart Hospital, Hallym University College of Medicine, Internal Medicine, Chuncheon, 2Asan Medical Center, University of Ulsan College of Medicine, Division of Gastroenterology, Seoul, and 3Asan Institute for Life Sciences, University of Ulsan College of Medicine, Division of Gastroenterology, Seoul, Korea

AIMS: To evaluate diagnostic ability of endoscopic ultrasound (EUS) elastography to distinguish benign from malignant solid pancreastic mass.

AIMS: Preoperative portal vein embolization (PVE) by percutaneous transhepatic approach has been performed in candidates of major liver resection including right hepatectomy and extended right hepatectomy. This procedure can increase volume of remnant liver and prevent post-operative hepatic failure. The aim of this study is to evaluate the technical feasibility and initial safety of endoscopic ultrasonography (EUS)-guided intrahepatic PVE in a live animal model. METHODS: EUS-guided intrahepatic PVE with coil and histoacryl was performed in seven pigs under general anesthesia using anterior oblique-viewing linear array echoendoscope. Under EUS guidance, the intrahepatic portal vein (PV) was punctured with a 19-gauge fine needle aspiration (FNA) needle, and a 0.035 inch embolization coil was inserted into the selected intrahepatic PV using a stylet as pusher. Then, 0.5 cc histoacryl was injected through the same FNA needle, immediately. The blood flow change in the selected intrahepatic PV

OBJECTIVES: 1. To characterize solid pancreastic mass based on elastography score. 2. To calculate elastography strain ratio. 3. To compare diagnosis based on elastography strain ratio/ elastography score of solid pancreastic mass with final pathological diagnosis. 4. To determine sensitivity and specificity of EUS elastography and strain ratio. METHODS: A single center study was conducted which included 38 patients who underwent EUS examination with assessment of solid pancreastic mass. The classification as benign or malignant, based on elastography score and elastography strain ratio was compared with the final diagnosis obtained by EUS-guided fine needle aspiration (EUSFNA).

RESULTS: Out of 38 cases 30 were malignant and 8 were benign. According to ROC curve (AUROC 0.82 (Confidence interval 0.60–1.0)) strain ratio cut off was 2.7. The sensitivity, specificity, positive predictive value and negative predictive value to differentiate benign from malignant solid pancreastic mass were 93.3%, 75%, 93.3% and 75%, respectively for strain


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ratio and 100%, 50%, 88.2% and 100%, respectively for elastography score. The kappa coefficient for solid pancreastic mass was 0.68 for strain ratio and 0.61 for elastography score.

CONCLUSIONS: EUS elastography is a new technique for differentiating benign and malignant solid pancreastic mass which measures difference in tissue stiffness between pathological and normal tissue. It is a promising modality with a high sensitivity, specificity and accuracy that may complement standard EUS in the differentiation of benign and malignant solid pancreastic mass and it might help for further management if EUS FNA turns out to be inconclusive. Conflict of Interest: None declared.

ENDOSCOPIC ULTRASOUND: ENDOSCOPY: EUS-FNA P421: IS PROCORE NEEDLE SUPERIOR TO STANDARD NEEDLE IN DIAGNOSING PANCREATIC CANCER VIA ENDOSCOPIC ULTRASOUND GUIDED FINE NEEDLE ASPIRATION AND BIOSPY Ji Kon Ryu, Jae Woo Lee, Sang Hyub Lee, Yong-Tae Kim Seoul National University College of Medicine, Department of Internal Medicine and Liver Research Institute, Seoul, Korea

AIMS: ProCore needle was designed to obtain core tissue under endoscopic ultrasound (EUS) guidance. However, there are conflicting results reported from previous studies, which have variable conclusions in the superiority of ProCore needle over standard fine needles. This retrospective study aimed to compare the technical and diagnostic yield of ProCore needle with the standard fine needle in diagnosing pancreatic cancer. METHODS: We reviewed all patients with pancreatic cancer from January 2015 to December 2015 who underwent EUSguided needle aspiration and biopsy carried out by two expert endoscopists. The only cases that used a 22-guage needle were included, and records of the needle, attempts of obtaining histologic sample, diagnostic yield of histology, overall diagnostic yield were obtained. Chi-square test was done to find out the difference of diagnostic yields.

RESULTS: A total of 181 patients were included in the study. Procore needle was used in 44 patients and standard needle in 137 patients. The overall diagnostic yield was 97.7% in ProCore group and 89.1% in standard needle group (P = 0.066). Twenty patients in Procore group and 80 patients in standard needle group had an attempt to obtain histologic samples. The technical success rate of obtaining diagnostic histological sample was 90% in ProCore group and 82.5% in standard needle group (P = 0.413). The overall diagnostic yield was 95.0% and 88.8% (P = 0.405) in the ‘attempt of obtaining histologic sample’ subgroup.

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 CONCLUSIONS: ProCore needle has a tendency to result in higher diagnostic yield and higher feasibility in obtaining histologic sample, but there was no statistically significant difference. Conflict of Interest: None declared.

P422: ENDOSCOPIC ULTRASOUND-GUIDED FINE NEEDLE ASPIRATION OF PANCREATIC LESIONS. EFFECTIVENESS AND COMPARISON BETWEEN 19G AND 22G NEEDLE♦ Carlos Frasca Rodrigues1, Nelson Coelho2, Claudio Rolim Teixeira3, Leonardo Conrado2, Michele Bonotto2 1 Fugast, Porto Alegre, Brazil, 2Fugast, Endoscopy, Porto Alegre, Brazil and 3Moinhos de Vento Hospital, Endoscopy, Porto Alegre, Brazil

AIMS: Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a highly sensitive and specific method for diagnosing pancreatic masses. To compare the efficacy of EUS-FNA using needles of different sizes (19G and 22G, Boston Scientific, Marlborough, MA, USA) in the diagnosis of solid and cystic pancreatic lesions. METHODS: From 2010 to 2015, 101 patients were referred for examination either due to abnormal imaging findings (suspect masses) or due to biochemical findings suggestive of pancreatic cancer. All patients underwent linear EUS-FNA, and specimens were analyzed using cell block preparations. Procedures performed from 2010 to 2013 used 22G needle, and from 2014 to 2015 a 19G needle.

RESULTS: Fifty patients underwent EUS-FNA with 22G needle and 51 with 19G needle. No complications occurred during the procedures. The final diagnosis was established by EUS-FNA with 22G in 30/50 patients, and with 19G in 43/51. Twenty-eight patients had undetermined diagnosis and were referred for surgery; of these, 15 had adenocarcinoma (10/20 in 22G and 5/8 in 19G). EUS-FNA with 22G was effective in diagnosis of benign diseases in 16/26 cases (3 pancreatitis, 6 serous cysts, 4 mucinous cysts, and 3 intraductal papillary mucinous neoplasms [IPMN]), and malignancies in 14/24 cases (11 adenocarcinomas, 1 neuroendocrine tumor, and 2 metastases). In the 19G group, benign diseases were diagnosed in 31/34 patients (12 serous cysts, 4 mucinous cyst, 8 IPMN, 4 pancreatitis, and 3 pseudocysts), and malignances in 15/20 patients (9 adenocarcinomas, 5 neuroendocrine tumor, and 1 metastasis). CONCLUSIONS: The diagnostic yield of EUS-FNA using 19G needles was significantly higher than obtained with 22G needles. Conflict of Interest: None declared.



P423: CLINICAL UTILITY OF KRAS MUTATION ANALYSIS OF EUS-FNA SAMPLES FOR DIAGNOSING PANCREATIC SOLID TUMORS Katsuhiro Kasahara, Bunji Endo, Seiko Hamada, Shigeharu Nakano, Kouki Chikugo, Tsubasa Shimogama, Ken Kumagai, Yoshiyuki Ohta, Naoki Esaka, Satoru Iwamoto, Yoshinori Mizumoto, Shinji Katsushima Kyoto Medical Center, Gastroenterology Division, Kyoto, Japan


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P424: TARGETED EUS FNA LIVER BIOPSY FOR MALIGNANT LIVER LESIONS Chai Soon Ngiu1, Zhiqin Wong1, Abdul Rani Rafiz2, Raja Ali Raja Affendi1 1 National University of Malaysia Hospital, Gastroenterology Unit, Department of Medicine, Kuala Lumpur, and 2 University Teknologi Mara, Gastroenterology Unit, Department of Medicine, Faculty of Medicine, Shah Alam, Selangor, Malaysia

AIMS: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) is considered to be useful for diagnosing pancreatic cancer. However, in some cases histopathological examinations based on EUS-FNA do not provide a definitive diagnosis. Kras gene mutations are common in pancreatic cancer and exhibit high specificity for the condition. We evaluated the utility of kras mutation analysis of EUS-FNA specimens for diagnosing pancreatic solid tumors.

AIMS: Endoscopic ultrasound (EUS) fine needle aspiration (FNA) of liver lesions is a emerging method for acquiring tissue for liver lesions. It is believe that this method maybe superior to traditional percutaneous liver biopsy (LB). We aim to describe our experience in safety and diagnostic yield of targeted EUS FNA-LB for malignant liver lesion in a tertiary care teaching hospital.

METHODS: Between 2011 and 2016, 85 patients underwent

FNA-LB of liver lesions. All EUS were performed by single operator with fanning method and no suction under consious sedation. Number of passes and complication of procedure were studied. All specimens procured were examined by on site cytotechnician for adequacy.

EUS-FNA examinations of suspected pancreatic solid tumors at our hospital. The suspected tumors were subjected to histopathological diagnosis, cytodiagnosis, and kras mutation analysis. We compared the results with the final diagnosis, which was obtained during surgery or an autopsy or based on the patient’s clinical findings. The EUS was performed with an Olympus GF-260UCT convex EUS scope, which was connected to an Aloka ProSound alpha 10 US machine.

RESULTS: Among the 85 patients, 72 were finally diagnosed with pancreatic cancer, and 54 of these patients underwent kras mutation analysis. In total, it was possible to diagnose 46 of the 54 patients (85.2%) with pancreatic cancer based solely on histopathological examinations. The combined use of kras mutation analysis resulted in pancreatic cancer being detected in 52 of the 54 patients (96.3%). Six patients with kras gene mutations in whom pancreatic cancer was not detected during the histopathological examination were eventually diagnosed with pancreatic cancer. In another 7 cases, no kras mutations were detected, but a histopathological examination resulted in a diagnosis of pancreatic cancer. There was only 2 patients that was diagnosed with pancreatic cancer after both the histopathological examination and kras mutation analysis produced negative results. CONCLUSIONS: Kras mutation analysis of EUS-FNA specimens is a useful supplementary tool for diagnosing pancreatic cancer. Conflict of Interest: None declared.

METHODS: Prospective review of patient underwent EUS

RESULTS: 3 EUS FNA-LBs were identified. Patients were diagnosed as cholangiocarcinoma, cancer of head of pancreas and pulmonary metastasis with unknown primary on presentation. Two patients had liver lesions on imaging. The mean size of the lesions were 12.7 mm (range 5.2–22.5 mm). EUS FNA-LB were performed due to lesion not accessible to percutaneous approach, and presence of intervening vessels at the primary lesion on EUS. EUS FNA-LB performed with trans-duodenal in one case and trans-gastric approach in two cases to right and left liver lobe respectively. Two passes were performed in cases performed via transgastric route with 22 g needle and one pass only in transduodenal approach with 25 g needle. All three patients had adequate sample for analysis. All patients were confirmed with pancareatobiliary malignancy. One patient passed away from advanced disease at review. Two patients currently receiving palliative chemotherapy. No complication of procedures were noted. CONCLUSIONS: EUS FNA-LB appears to be a safe and feasible technique for procuring tissue for visible liver lesions with excellent tissue adequacy. Conflict of Interest: None declared.

P425: INSULINOMA: A CASE REPORT Than Than Aye University of Medicine 2, Gastroenterology, Yangon, Myanmar

AIMS: Pancreatic endocrine tumors are rare lesions, with a reported incidence of four cases per 1 million patient-year. Of


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these lesions, insulinomas are the most common. They are insulin-secreting tumors of pancreatic origin that cause hypoglycemia. Diagnosis can be challenging even with EUS FNA.

METHODS: A 35 year old male had history of episodic and repetitive symptom of palpitations, tremors, diaphoresis, occasional loss of consciousness and sometime fits since 9 years (since 2007) and many times he was brought to the hospital and found to have low blood sugar levels, His BMI was 38.2 kg/m2. Investigations on profound hypoglycaemia were done when he consulted with endocrinologist. Glucose - 15 mg/dL (74– 106 mg/dL), Insulin - 152.9 uU/mL (3–17 uU/mL), C-peptide 13.09 ng/mL (1.1–4.4 ng/mL), Insulin/Glucose ratio >0.3 (10.19). He was highly suspicious in Insulinoma. Both repeated CT and MRI were normal apart from two small calcifications at the tail of the pancreas in CT. Then he was sent to us for EUS examination. Well defined hypoechoic mass measured about 14 x 11 mm at the tail of the pancreas was found. EUS guided FNA done and cytology reported small round cell neuroendocrine tumor.

RESULTS: He underwent surgery.15 x 10 mm mass was confirmed and distal pancreatectomy was done. Pathological report was Mixed Acinar Endocrine Carcinoma. The glucose level increased to 351 mg/dL immediately after operation and then became normal. Uneventful surgery except peri-pancreatic fluid collection which resolved with aspiration. The patient remains asymptomatic within 6 months follow up.

METHODS: It was a prospective, randomized, single-institution study from January to August 2016. We enrolled twelve patients diagnosed as pancreatic solid mass referred for EUSFNA. For each session of EUS-FNA we performed five punctures. Five groups were divided and the details were as follows: group 1 (company A 22G FNA needle (A), with stylet (stylet+), with suction (suction+), fanning technique); group 2 ((A), stylet+, suction-, fanning technique); group 3 ((A), stylet+, suction+, traditional method); group 4 (company B 22G FNA needle (B), stylet+, suction+, fanning technique); group 5 ((B), stylet+, with slow pull (slow pull+), fanning technique). We sent our specimens for cytological smear and histologic evaluation.

RESULTS: Total twelve sessions of EUS-FNA were performed. Overall positive rate of cytological smear was 75% (9/12). Overall positive rate of histology was 59% (7/12). The histologic diagnoses included malignancy (all 7 cases were adenocarcinoma), dysplastic cell, atypical cell, inflammatory cell and negativity. As for the subgroup analysis group 1 and group 4 demonstrated higher yield rate (42% for each) and the next was group 5 following by group 2 and group 3. CONCLUSIONS: Considering EUS-FNA for pancreatic solid mass, combination with stylet, keeping negative pressure with suction and fanning technique might be the better combined variables of choice for higher yield rate of histology. Our major pitfall is the very small sample size. Conflict of Interest: None declared.

CONCLUSIONS: Insulinoma is rare and diagnosis is challenging despite various diagnostic modalities. High index of clinical suspicion is important and EUS is a highly reliable procedure for the preoperative localization and EUS FNA revealed accurate histological diagnosis. Experienced pathologist takes the important role in histological examination. Conflict of Interest: None declared.

P427: COMPARISON OF SPECIMEN ADEQUACY AND DIAGNOSTIC PERFORMANCES ACCORDING TO EUS-FNA TECHNIQUES IN PANCREATIC LESIONS: NO SUCTION, SUCTION AND CAPILLARY SUCTION Chang Min Cho1, An Na Seo2, Han Ik Bae2 1

P426: COMPARISON BETWEEN VARIABLES FOR EUS-FNA OF PANCREATIC SOLID MASS Hsiang Yao Shih1,2, I Ting Chen3, Meng Chieh Wu2, Wen Hon Hsu1, Deng Chyang Wu1,2 1

Kaohsiung Medical University Hospital, Gastroenterology, Kaohsiung Municipal Tatung Hospital, Gastroenterology, and 3Kaohsiung Medical University Hospital, Pathology, Kaohsiung, Taiwan, China 2

AIMS: EUS-FNA is the preferred method for obtaining the specimen from a pancreatic solid mass. During this procedure some variables might affect the yield rate and quality of the specimen such as the use of stylet or not, keeping negative pressure by suction or slow pulling and aspiration technique with traditional method or fanning technique. Nowadays it seems there is no definite suggestion about the combination of the above variables for better yield rate and quality of specimen. We designed the study for trying to find out the preferred combination of variables.

Kyungpook National University Medical Center, Internal Medicine, and 2Kyungpook National University Medical Center, Pathology, Daegu, Korea

AIMS: Different types of endoscopic ultrasound-guided fineneedle aspiration (EUS-FNA) techniques are used in clinical practice. However, controversy still remains as to which techniques would result in better adequate specimen and diagnostic accuracy. The aim of our study was to compare specimen adequacy and diagnostic performances according to EUS-FNA techniques (no suction vs suction vs capillary suction) in a patient with pancreatic lesions. METHODS: Patients who referred to EUS-FNA for pancreatic mass lesion were enrolled. We performed EUS-FNA with three needle passes and applied different FNA techniques (suction, no suction or capillary suction) which were randomly allocated. Additional needle passes were allowed to obtain an adequate specimen after the initial three needle passes without adequate specimen. EUS-FNA specimens were evaluated by one experienced cytopathologist who was blinded to which EUS-FNA techniques were applied. The specimen adequacy and




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diagnostic performances for malignancy were compared among EUS-FNA techniques.

for liver masses was not different (25/28, 89.3% vs 13/14, 92.9%, P = 0.86). No complications developed after procedure.

RESULTS: From Jan. 2014 to Oct. 2015, 113 patients with pancreatic mass were enrolled and 4 patients were excluded due to loss of follow up after EUS-FNA. Finally, 109 patients (65 males; median age, 67 years) with 327 needle passes were included without technical failure. The cumulative diagnostic accuracy for malignancy for overall needle passes was 61.5%, 84.4% and 91.7% at 1st, 2nd and 3rd pass, respectively. Although high rate of inadequate specimen in EUS-FNA with capillary suction was occurred, there was no significant differences among EUS-FAN techniques and number of needle pass. EUS-FNA with no suction at 2nd needle pass showed statistically high rate of diagnostic accuracy comparing to suction at 2nd pass and no suction at 1st and 3rd pass (P = 0.016, 0.051, 0.034).

CONCLUSIONS: EUS-FNA can be safe and efficient method

CONCLUSIONS: EUS-FNA with no suction, suction and capillary suction showed similar rate of inadequate specimen. However, further prospective study including variable lesions is needed to validate for optimal application and sequences of EUS-FNA techniques. Conflict of Interest: None declared.

P428: ENDOSCOPIC ULTRASOUND-GUIDED FINENEEDLE ASPIRATION CAN TARGET RIGHT LIVER MASS Dongwook Oh, DonDong-Wan Seo, Seung-Mo Hong, Tae Jun Song, Do Hyun Park, Sang Soo Lee, Sung Koo Lee, MyungHwan Kim Asan Medical Center, Seoul, Korea

AIMS: Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) has been established as a safe and accurate method for diagnosing and staging intra-abdominal mass. However, few studies investigated its feasibility, efficacy and safety for targeting liver mass. We evaluated the efficacy and safety of EUS-FNA in patients with liver masses including right lobe. METHODS: The technical feasibility, safety and diagnostic yield were determined in 47 patients (30 in left lobe and 17 in right lobe) presenting with liver masses between September 2010 and February 2016.

RESULTS: Thirty-eight patients (90.9%) had malignancies whereas nine patients (19.1%) had benign liver masses. Technical success rates were 97.9% (46/47). EUS-FNA was diagnostic in 38 of 42 patients (82.6%). When the outcomes of EUS-FNA between right liver mass and left mass, the technical success rates were similar in both lobes (100% vs 94.1%, P = 0.2). The median tumor size on EUS (25.5, IQR 13.8–30.3 vs 28, IQR 18.5– 43.5, P = 0.24) and number of needle passes (3, IQR 3–4 vs 3, IQR 3–3, P = 0.24) were not significantly different. Adequate specimen obtained statistically higher in the left lobe (28/30, 93.3% vs 14/17, 82.4%, P = 0.04). However, diagnostic accuracy

for the diagnosis of liver mass and was technically feasible even for those in the right lobe. Conflict of Interest: None declared.

P429: EUS AS A PRIMARY DIAGNOSTIC MODALITY IN PROXIMAL BILIARY STRICTURES Rachit Agarwal, Vikas Singla, Anil Arora Sir Gangaram Hospital, Gastroenterology, New Delhi, India

AIMS: Tissue diagnosis of Proximal biliary strictures (PBS’s) remains challenging, because of limitations of the available diagnostic modalities. The aim of this study was to assess diagnostic accuracy of Endoscopic ultrasound (EUS) guided FNA (Fine needle aspiration) as a primary modality to establish tissue diagnosis in PBS’s. METHODS: Data of all patients with PBS’s who underwent EUS from April 2011 to July 2015 was recorded. FNAC was taken from unresectable lesions and cytopathological analysis was done.

RESULTS: 123 patients underwent EUS for PBS’s. Lesion was identifiable in 117 (95.1%) patients. 64 (54.7%) were from common bile duct (CBD), 46 (39.3%) were arising from gall bladder (GB) neck, 6 (5.1%) had portal biliopathy and 1 (0.9%) had post cholecystectomy benign stricture. 83 lesions were unresectable based on combined CT and EUS findings and FNA was taken for tissue diagnosis. Cytopathology showed adenocarcinoma in 67 (80.7%), tuberculosis in 3 (3.6%), HCC in 1 (1.2%), benign pathology in 8 (9.6%) and insufficient material in 4 (4.8%). Success rate to determine etiology was (71/83) 85.5%. 12 patients who had benign/insufficient material underwent ERCP with brush cytology. Three were found to be malignant, 1 had eosinophilic cholangitis and 1 had CBD stone. 4 patients were lost to follow up and were considered as malignant disease. 3 were benign on brush cytology and were confirmed inflammatory strictures on surgery. Thus, to diagnose malignant disease the sensitivity of EUS was 93.1%, specificity was 100%, Positive predictive value was 100%, Negative predictive value was 53.3 %, and diagnostic accuracy was 91.5%. CONCLUSIONS: EUS is a high potential diagnostic modality for primary evaluation of PBS’s in view of high accuracy and excellent diagnostic yield. Conflict of Interest: None declared.


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P430: ROLE OF EARLY ENDOSCOPIC ULTRASOUND IN IDIOPATHIC ACUTE PANCREATITIS♦ Piyush Somani, Malay Sharma Jaswant Rai Speciality Hospital, Department of Gastroenterology, Meerut, India

AIMS: The cause of acute pancreatitis (AP) remains elusive even after extensive work up in up to 30 % of cases. Finding a treatable cause may help to prevent recurrent episodes. The aim of our study was to determine the efficacy of early endoscopic ultrasound (EUS), performed within 24 h of admission, in evaluating the etiology of idiopathic acute pancreatitis (IAP) after a first attack of AP. METHODS: During the study period (2010–2015), 850 cases of AP were admitted. Out of these, aetiology was determined in 666 (78.35 %). There were 184 cases of IAP. EUS examination was done using a linear echo endoscope.

RESULTS: Out of 158 cases (90 males; age range: 15– 70 years) of IAP, (26 were excluded) EUS was able to clinch the diagnosis in 110 patients (69.6 %). The most common causes of IAP included biliary disease (gallbladder microlithiaisis, common bile duct microlithiasis/stone/sludge) (n = 60) followed by chronic pancreatitis (CP) (n = 25), pancreatic tumour (n = 11) and pancreaticobiliary ascariasis (n = 9). No cause was found in 48 patients. CONCLUSIONS: Occult biliary stone/sludge was the predominant cause for IAP followed by CP. EUS is a safe investigation with a high diagnostic yield for determining the etiology of IAP and an early EUS can influence important therapeutic decisions and prevent further attacks of AP which may occur if a delayed EUS is performed and thus improve long term prognosis. An early EUS also has an additional advantage of making an early diagnosis of pancreatic tumours. It also prevents making the wrong diagnosis of sludge as etiological factor for AP which may occur in patients undergoing a delayed EUS since sludge may be secondary to AP due to prolonged fasting, total parenteral nutrition or antibiotics like ceftriaxone. Conflict of Interest: None declared.

P431V: EUS GUIDED FNA OF OVARIAN MASS AND OMENTAL DEPOSITS Piyush Somani, Malay Sharma Jaswant Rai Speciality Hospital, Meerut, India

AIMS: In spite of the modest size of the ovaries, they are frequently the site of many physiological and pathological lesions which can be classified into non-neoplastic and neoplastic lesions. Ovarian Fine needle aspiration cytology (FNAC) can help in differentiation of ovarian lesions. It is usually performed under ultrasonography (USG) or Computed tomography (CT) guidance. Potential role of ovarian FNAC

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 Differentiation between neoplastic and non-neoplastic lesions Classification of neoplastic lesions into benign, borderline malignant and malignant Differentiation between primary ovarian malignancy and metastasis to ovary We present a novel technique of Endoscopic ultrasound (EUS) guided FNAC of ovarian mass from rectum

METHODS: 65-year-old hypertensive woman with H/O bypass surgery presented with abdominal distension since one month and weight loss. CT (Abdomen) revealed gastric wall thickening, omental thickening, ascites and left adnexal mass measuring 4.5 x 5 cm. CEA and CA-125 were elevated. Gastroscopy was normal Being a poor surgical candidate, EUS was planned to define the primary diagnosis EUS performed from upper rectum revealed hypoechoic ovarian mass. FNAC was performed with 22 Gauge needle. EUS performed from stomach revealed hyperechoic omental deposits. FNAC was performed with 22 Gauge needle.

RESULTS: Ovarian and omental FNAC (H&E stain) revealed small clusters, acinar formations & scattered atypical epithelial cells having high N:C ratio, hyperchromatic nuclei & moderate amount of cytoplasm. Immunohistochemistry: Tumour cells positive for cytokeratin 7, CEA, CA 19.9 and vimentin, negative for CK20 and WT-1 confirming primary mucinous ovarian cancer. Final diagnosis: Primary Ovarian mucinous malignancy stage 3C Patient underwent neoadjuvant chemotherapy CONCLUSIONS: This case demonstrates the potential use of EUS in ovarian lesions Adequate samples for immunohistochemistry is possible with EUS-FNA Imaging is better because of proximity to ovary and use of high frequency probes Further studies are required to explore the use of EUS in adnexal masses Conflict of Interest: None declared.

P432: DOES CA19.9 ACCURATELY PREDICT MALIGNANCY IN PATIENTS WITH PANCREATIC MASS? A COMPARATIVE STUDY WITH EUS FNAC Jahangeer Basha, Sundeep Lakhtakia, Rajesh Gupta, Mohan Ramachandani, Rakesh Kalapala, Partha Pal, Anuradha Sekharan, D. Nageshwar Reddy Asian Institute of Gastroenterology, Gastroenterology, Hyderabad, India

AIMS: To compare the CA19.9 level with cytopathology obtained by EUS FNAresults in patients with mass lesion in pancreas and to evaluate the efficacy of CA19.9 in predict the malignancy. METHODS: Consecutive patients with mass lesion in pancreas were includedfrom May 2013 to April 2014. CA19.9 levels were


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 measured in all patients by Electro chemi-luminescence method, Roche Diagnostics with cut off value for positive result being >27 U/mL. EUS guided FNA was performed using either 22G or 25G needle depending on the feasibility and tumour location. Aspirated samples were analysed for cytology and histology (cell block / core biopsy). Confirmation of malignancy was based on cytology / histology obtained by EUS FNA, pathology of surgical specimens in patients who underwent surgery, and on prolonged clinical follow up.

RESULTS: 152 patients (mean age 55.3 12 years; males 71%) with mass lesion in pancreas underwent EUS guided FNA. The mean and median levels of CA 19.9 levels were 1557.73 U/ mL and 150.6 U/mlwith range from 1 U/mL to 10000 U/mL. CA 19.9 was elevated in 112 (73.7%) patients and normal in 40 (26.3%) patients. Malignancy was detected in 100 (65.8%) and 52 (34.8%) patients had no evidence of malignancy. The mean CA 19.9 level in patients with malignancy was significantly higher than those without malignancy (P < 0.001). However, of those with normal CA 19.9 levels malignancy was detected in 10 patients with false negativity rate of 6.5%. Malignancy was not detected in 21 patients with elevated CA 19.9 levels with false positivity rate 13.8%. There was no significant correlation between bilirubin levels and CA19.9. ROC curve showed that a cut off of 43.7 U/mL, had a sensitivity 88% and specificity 75% with area under the curve 0.85. CONCLUSIONS: Though CA19.9 appears to be good marker to predict malignancy, false positivity and false negativity rates limit its accuracy. A higher cut off value increases the positive predictive value. Conflict of Interest: None declared.


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44 (35.5%) women. EUS-FNA yielded tissue diagnosis in 114 (91.93%) patients and was inconclusive in 10 (8%) patients. Among the sampled lesions, 65 (65/124 = 52.42%) patients had granulomatous lymphadenitis, 28 (22.58%) had neoplastic lesion (Ca Lung: Small Cell Ca-3; Non-small cell Ca: 6 x Squamous Cell Ca; 9x AdenoCa) and Metastatic Carcinoma (2 x Ca Breast; 8x Poorly Differentiated Ca). 7 patients had NHL and 4 patients sarcoidosis. The sensitivity and specificity of EUSFNA were 95% and 100% respectively. None of the patients had serious adverse events.

CONCLUSIONS: We conclude that EUS FNA is a safe technique and is a useful tool for guiding clinical management in patients with mediastinal lymphadenopathy of unknown origin. Conflict of Interest: None declared.

P434: MACROSCOPIC ON-SITE QUALITY EVALUATION OF BIOPSY SAMPLE FOR THE DIAGNOSTIC ACCURACY DURING EUS-GUIDED FNA USING A 19-G NEEDLE FOR SOLID LESIONS: A SINGLE-CENTER PROSPECTIVE STUDY Mahesh Gupta, Gaurav Patil, Sumit Bhatia, Nisarg Patel, Rinkesh Bansal, Rajesh Puri, Randhir Sud Medanta - The Medicity, Gurgaon, India

AIMS: To assess the efficacy of Macroscopic on-site quality evaluation (MOSE) in estimating the adequacy of histologic core specimens obtained by EUS-FNA using a standard 19-gauge needle (19GN) for solid lesions. METHODS: A prospective study conducted in a tertiary care

P433: YIELD OF ENDOSCOPIC ULTRASOUND GUIDED FNA IN THE EVALUATION OF MEDIASTINAL LYMPHADENOPATHY Santoshkumar Ambulge1, I Satish Rao2, Nitesh Pratap1, Sethu Babu1, Ramakrishna K.A1, Sharat Putta1 1

Krishna Institute of Medical Sciences, Medical Gastroenterology, and 2Krishna Institute of Medical Sciences, Pathology, Hyderabad, India

AIMS: To evaluate the yield and safety of EUS FNA in the diagnostic evaluation of mediastinal lymphadenopathy. METHODS: Settings: Tertiary care Referral Center (KIMS Hospital, Secunderabad) Design: Retrospective analysis of a prospectively collected data from October 2012 to September 2016. Total of 124 consecutive patients were enrolled into the study. EUS-FNA was performed with a linear echoendoscope using 22 or 25G needle. Tru cut biopsy was performed wherever feasible & sent for histopathology.

hospital in north India. All consecutive adult patients presenting for EUS -FNA of solid organ lesions or lymph nodes were included in this study after proper consent. A total of 40 patients were included.

RESULTS: The feasibility of EUS-FNA using a 19G was 99%. The final diagnoses were malignancy in 30 lesions and benign in 10. MOSE revealed MVC in 95% with the median length of 8 mm. Histologic core was confirmed in 80%. The receiver-operating characteristic curve of the length of MVC for the presence of histologic core showed the cut-off MVC length of 4 mm with area under the curve of 0.90. Comparisons of per-pass diagnostic yields showed significantly superior histologic, cytologic, and overall diagnostic yields in MVC ≥4 mm as compared with < 4 mm. No significant adverse events were seen. CONCLUSIONS: MVC of ≥4 mm on MOSE can be an indicator of specimen adequacy and can improve diagnostic yield. Conflict of Interest: None declared.

RESULTS: 124 consecutive Patients with mediastinal lymphadenopathy underwent EUS-FNA. 80 (64.5%) were men and


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P435V: EUS - FNA OF PERITONEAL LIGAMENT DEPOSITS IN OVARIAN MASS

ENDOSCOPIC TECHNOLOGY: ENDOSCOPY: NATURAL ORIFICE – NOTES

Piyush Somani, Malay Sharma

P436: NOVEL ENDOSCOPIC SUTURING DEVICE USING CURVED NEEDLE: EX VIVO ANIMAL STUDY

Jaswant Rai Speciality Hospital, Meerut, India

AIMS: Double layered peritoneal folds or ligaments act as conduits for the passage of blood vessels in intraperitoneal organs and also provide a pathway for the spread of disease. Metastasis within ligaments is of clinical importance as the peritoneal surface metastases are stage III while liver metastases suggest stage IV disease. Endoscopic ultrasound (EUS) of peritoneal ligament can be useful for group staging of luminal malignancy; for sampling of station nodes; and for decision making regarding neoadjuvant therapy without laparoscopy/laparotomy. Intraperitoneal dissemination is the most common mode of extension of ovarian cancers.

METHODS: We present series of 2 patients with ovarian masses where EUS fine needle aspiration (FNA) played an important role in the diagnosis. First patient was diagnosed with epithelial ovarian cancer 4 years ago, when she underwent surgical resection associated with adjuvant chemotherapy. On follow up, CA 125 was elevated. PET -CT revealed dense peritoneal fat in the lower abdomen besides showing heterogeneous parietal gastric thickening. Linear EUS revealed thickened hyperechoic gastrocolic ligament with hypoechoic deposits which were punctured with 22Gauge needle. Histopathology confirmed the diagnosis of metastatic serous cystadenocarcinoma, the immunohistochemical (IHC) study indicated the gynecological tract as the primary site.

RESULTS: Second patient had suspected ovarian mass around 3 cm on CT (abdomen) with mildly raised CA 125. EUS performed from upper rectum revealed normal size ovary with hyperechoic ovarian ligament. Hypoechoic irregular deposits were seen on ligament and EUS - fine needle aspiration was performed with 22 G needle. Histology confirmed malignancy with IHC suggestive of ovarian origin. Patient underwent surgery. CONCLUSIONS: EUS of peritoneal ligaments can play an important role in staging of ovarian and intraabdominal malignancy. It may provide sample to confirm the diagnosis with immunohistochemistry. Further studies are required to explore its value in oncology. Conflict of Interest: None declared.

Sang Yup Lee, Hyuk Soon Choi, Jung Min Lee, Byeong Kwang Choi, In Kyung Yoo, Seung Han Kim, Jae Min Lee, Eun Sun Kim, Bora Keum, Yoon Tae Jeen, Hoon Jai Chun, Hong Sik Lee, Chang Duck Kim Korea University College of Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul, Korea

AIMS: Nonsurgical endoscopic closure of the gastrointestinal wall may be desired in many situations, such as fistulae, perforation with the emerging and development of natural orifice transluminal endoscopic surgery (NOTES) as a minimally invasive surgical platform, endoscopic suturing is especially important. Here, we studied the feasibility of novel endoscopic suturing device by demonstrating the strength of closure in ex vivo animal study. METHODS: A total of 30 porcine stomachs were used for the test. Standard gastrotomy was made on each stomach by blade incision. Porcine stomachs were assigned randomly to 3 groups and closed by new endoscopic closer with curved needle (Encloser), endoscopic clips and hand sewn. Each stomach was inflated by an automated pressure gauge. After that, the stomach was dipped in water and air leakage pressure was measured by automated pressure gauge when an air bubble was first observed.

RESULTS: . The average leakage pressure for the En-closer, Endoclip, and full-thickness hand sutures was 43.25 mmHg, 44.10 mmHg, and 63.19 mmHg. The average closer strength of the En-closer does not significantly differ from that of the Endoclip (P > 0.05). The standard deviation for the En-closer, Endoclip, and full-thickness hand sutures was 6.37 mmHg, 14.35 mmHg, and 12.97 mmHg, respectively. The standard deviation of the En-closer is significantly smaller than that of the Endoclip and full-thickness hand sutures (P < 0.05). It is determined that the closer strength of the En-closer does not significantly differ, but is more consistent than the closer strength of the Endoclip. CONCLUSIONS: The En-closer, which can performs multiple stitches with a single endoscope insertion showed feasible result comparing with Endoclip and hand-sewn suture. This research proposes a novel approach for minimally invasive endoscopic surgery. Conflict of Interest: None declared.



P437V: BY TRANSRECTAL NATURAL ORIFICE TRANSLUMENAL ENDOSCOPIC SURGERY (NOTES) FOR REMOVING STONE AND SAVING GALLBLADDER FOR ONE EXAMPLE Liu Ai-Min1, Wy Shen2, T. Wu2, S. Wei2, Y. Xue2 1

Chongqing Fuling Central Hospital 408099, Department of Gastroenterology, Chongqing Municipality, and 2Chongqing Fuling Central Hospital, Chongqing, China

AIMS: To explore the safety and complicationsof the NOTES for removing stone and saving gallbladder. METHODS: Patient, xx, female, 52, admitted to hospital by transrectal natural orifice translumenal endoscopic surgery for removing the stone and saving gallbladder, because of right upper quadrant pain 15 years repeatedly and diagnosing single gallbladder stone with abdominal color doppler.

RESULTS: This example was undergone by transrectal NOTES for treatment gallstone, without postoperative hemorrhage, infection, late-onset complications such as perforation, abdominal abscess.

CONCLUSIONS: NOTES is still faced with much challenge, along with the continuously research, the NOTES will gradually spread in clinic. Conflict of Interest: None declared.


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was retracted to reduce the volume and was tied using the knotting device. After the suture procedure, water was reinjected to check the volume of the stomach. And we performed pig studies to evaluate safety and feasibility of this method.

RESULTS: We performed ten in vivo animal studies. Mean volume was 1873.5 mL before the experiment, but the volume reduced to 1304 mL after the end of experiment. We could confirm about 29.9% volume reduction. All of the stitches were securely sutured with full thickness. The study showed that suturing of full thickness using continuous closure device resulted in the decrease of volume. We performed 10 short term experiments in a porcine model. It is possible to reduce gastric volume in live porcine model, and pigs had been survived for 30 days before sacrifice without complication. There were no technical problems during the procedure. Endoscopic gastric reduction with our device is technically feasible on a live porcine model. CONCLUSIONS: It is possible to achieve transoral endoscopic gastroplasty with an endoscopic continuous suture device. Conflict of Interest: None declared.

P439: THE CLINICAL VALUE OF ETIOLOGICAL DIAGNOSIS OFUNEXPLAINED ASCITES BY THE TRANSGASTRIC NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES) Jing Tang

P438: AN ENDOSCOPIC GASTROPLASTY FOR OBESITY TREATMENT USING NEW KUMC ENDOSCOPIC SUTURE DEVICE: IN VIVO ANIMAL STUDY Byeong Kwang Choi, Sang Yup Lee, Hyuk Soon Choi, Hoon Jai Chun, Yoon Tae Jeen, Bora Keum, Chang Duck Kim, Eun Sun Kim, Seung Han Kim, Hong Sik Lee, Jae Min Lee, In Kyung Yoo, Jung Min Lee Korea University Anam Hospital, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul, Korea

AIMS: Obesity is a major health problem worldwide. The primary treatment for obese patients is weight reduction, which can improve comorbidity. Procedure to reduce gastric volume has been widely used for surgical treatment of morbid obesity. Recently, it is reported that there is an effect on metabolic diseases such as diabetes. An endoscopic approach to treat obesity may be less invasive than laparoscopy or surgery. We made an endoscopic suture device with suction cap for reducing stomach volume. The objective of this study is to evaluate the feasibility and effectivenss of an endoscopic suturing procedure for weight loss in vivo.

Fuling Center Hospital of Chongqing, Chongqing, China

AIMS: to explore the clinical value of etiological diagnosis ofunexplained ascites by the transgastric natural orifice transluminal endoscopic surgery (NOTES). METHODS: to review 12 cases of abdominal cavity of unknown causes ascites and peritoneal biopsy in patients with clinical data in our hospital in November 2015 to July 2016 by the NOTES.

RESULTS: after abdominal exploration, peritoneal biopsy pathology confirmed, and the diagnosis rate was 100%, including 8 cases of tuberculous peritonitis, 2 cases of liver cirrhosis, 1 cases of peritoneal mesothelioma, and 1 case of metastatic peritoneal carcinoma. CONCLUSIONS: The transgastric NOTES abdominal probe and peritoneal biopsy in the diagnosis of unexplained ascites have important clinical application value of smaller trauma, shorter operation time, lower operation cost, fewer complications, faster recovery, and is worth popularizing widely. Conflict of Interest: None declared.

METHODS: A prototype suture device was created using needle, beads and suction cap. This novel device was used to suture wall of the fundus and body. After suturing, the thread


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P440V: ENDOSCOPIC TRANSESOPHAGEAL EXTRALUMINAL TUMOR RESECTION

CONCLUSIONS: Serosal OTSC closure was feasible, safe and efficient. It required a longer time to perform due to increased technical difficulty. Serosal OTSC closure does not seem to add any benefit to the standard mucosal OTSC closure. Conflict of Interest: None declared.

Mingyan Cai, Pinghong Zhou, Jianwei Hu Zhongshan Hospital, Fudan University, Endoscopy Center, Shanghai, China

AIMS: This video describes a case of an extraluminal tumor successfully resected by natural orifice transluminal endoscopic surgery. An abdominal ultrasound showed a 1.5 cm x2.0 cmmass near gastric cardia, suggesting a gastric stromal tumor (GIST). METHODS: Endoscopic transesophageal extraluminal tumor resection by tunneling techinque was performed.

RESULTS: The tumor was successfully removed endoscopicly. The pathology proved the tumor to be a schwannoma. The patient recovered uneventfully after three days of hospital stay.

ENDOSCOPIC TECHNOLOGY: ENDOSCOPY: NEW IMAGING TECHNOLOGY P442: IMPROVEMENT OF DIAGNOSTIC ACCURACY OF NBI IMAGES TO DIAGNOSE PREMALIGNANT LESIONS OF ESOPHAGUS AND STOMACH Nina Mitrakova1, Raisa Smirnova2, Alexander Mitrakov2, Evgeniya Peganova1, Elena Golodyuk1, Viktor Ryzhkov1 1

Republican Clinical Hospital, Endoscopy, Yoshkar-Ola, and Nizhny Novgorod Regional Clinical Oncological Center, Endoscopy, Nizhny Novgorod, Russia 2

CONCLUSIONS: Endoscopic tunneling technique provides a safe access to extraluminal lesion for endoscopic resection. Thoracic NOTES is promising. Conflict of Interest: None declared.

P441: MUCOSAL VS SEROSAL OTSC CLOSURE IN NOTES: A RANDOMIZED CONTROLLED STUDY 1

1

2

AIMS: The aim of research is to increase the diagnostic value of NBI in verification of premalignant lesions of esophagus and stomach by means of method automatically detecting abnormalities received in the course of examination. METHODS: The research covered 1740 high resolution

2

Tomas Hucl , Marek Benes , Matej Kocik , Jana Maluskova , Eva Kieslichova2, Martin Oliverius2, Julius Spicak1 1 Institute of Clinical and Experimental Medicine, Gastroenterology and Hepatology, and 2Institute of Clinical and Experimental Medicine, Prague, Czech Republic

AIMS: Over the scope clip (OTSC) has become a widely accepted technique of transluminal closure in NOTES. However, the usual clip application is based on mucosa approximation and does not fulfill the surgical principle of serosa-to-serosa approximation in hollow organ closures. The aim of the study was to evaluate the feasibility, safety and efficiency of serosal OTSC closure in comparison to the standard mucosal OTSC closure. METHODS: Animals were randomized to receive either mucosal (10 animals) or serosal (10 animals) OTSC closure. In mucosal closure, the mucosal portions of the incision edges were approximated by a double grasper and pulled into the clip´s cap, whereas in serosal closure, the serosal portions of the incision edge were grasped, approximated and pulled into the cap.

RESULTS: All OTSCs were applied successfully in a mean time of 5.3 min (range 2–7 min) in the mucosal group and in a mean time of 8.8 min (range 4–12 min) in the serosal group (P = 0.001). Necropsy demonstrated patent full-thickness gastric closure with no macroscopic signs of infection in all animals. Histologically, the mucosal closure was characterized by an end to end apposition of the gastric wall layers, whereas the serosal closure was characterized by a side to side apposition of the layers.

esophagogastroscopies with NBI. Average age of the examined patients was 49 11. Received narrow band images were subjected to color segmentation with the help of the “EndoView” and “Endoskopist Assistant “ Programs. Color characterictics of NBI images were analysed using special software created using C# language. The software allows establishing correspondence between NBI image pixel and definite colors (pink, blue, grey, lilac) and forming the image of mapping results of color distribution. The palette may change depending on the type of study. According to the results of NBI image statistic analysis standard pallets were made to summarize information about color characteristics of healthy and pathologic tissues. The software permits analysing images and video files obtained in real time or taken from archives.

RESULTS: Among patients with atrophy gastritis intestinal metaplasia was detected in 7.7% cases, low -grade epithelial dysplasia - in 2.9% cases, high-grade epithelial dysplasia/ incipient neoplasia was detected in 0.9% cases. A new method allowed to diagnose patients with Barret’s esophagus in 1.16%, patients with intestinal metaplasia - 0.25%, patients with a low grade dysplasia - 0.16% and patients with a high grade dysplasia/early cancer of esophagus - 0.25%. CONCLUSIONS: The method of quantitative analysis of pathological changes in NBI images allows the endoscopist to objectify the results obtained. It minimizes the number of missed precancerous lesions and early cancers of esophagus and stomach and reduces mortality from oncological diseases. Conflict of Interest: None declared.



P443: EVALUATION OF AN INNOVATIVE 3D COLONOSCOPE SHAPE SENSING SENSOR BASED ON FBG SENSOR ARRAY In Kyung Yoo, Hoon Jai Chun, Jung Min Lee, Byeong Kwang Choi, Sang Yup Lee, Jae Min Lee, Seung Han Kim, Hyuk Soon Choi, Eun Sun Kim, Yoon Tae Jeen, Hong Sik Lee, Chang Duck Kim Korea University Anam Hospital, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul, Korea


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P444: FULL SPECTRUM ENDOSCOPY (FUSE) IN THE DETECTION OF INFLAMMATORY BOWEL DISEASE NEOPLASIA (FUSION): A RANDOMIZED CROSSOVER TANDEM STUDY VS CONVENTIONAL COLONOSCOPY Rupert Leong, Marie Ooi, Crispin Corte, Yunki Yau, Melissa Kermeen, Peter Katelaris, Charles Mcdonald, Meng Ngu Concord Hospital, Gastroenterology and Liver Services, Sydney, Australia

comfort, and safety are important factors. Uncontrolled looping of the colonoscope shaft during insertion can cause abdominal pain and could lead serious complications. Scope guided endoscopy using ultrathin shape sensor can reduced unnessessory tactile pressure or torque. The aim of this study is to simulate 3D structure of colonoscope using ultrathin shape sensor.

AIMS: Inflammatory bowel diseases (IBD) increase the risk of colorectal cancer. Short surveillance intervals are recommended due to the low sensitivity of dysplasia detection on conventional forward-viewing colonoscopy (FVC), even after chromoendoscopy. Full Spectrum Endoscopy (FUSE) incorporates 2 additional cameras to the forward camera of the colonoscope to visualize behind folds and in blind spots and may improve early dysplasia detection. This study aims to assess FUSE vs FVC in IBD dysplasia surveillance.

METHODS: During colonoscopy, procedural completion,

METHODS: A prospective, single-center, randomized-order,

AIMS: During colonoscopy, procedural completion, accuracy,

accuracy, comfort, and safety are important factors. Uncontrolled looping of the colonoscope shaft during insertion can cause abdominal pain and could lead serious complications. Scope guided endoscopy using ultrathin shape sensor can reduced unnessessory tactile pressure or torque. The aim of this study is to simulate 3D structure of colonoscope using ultrathin shape sensor.

RESULTS: Total 10 patients was performed colonoscopy using ultrathin shape sensor. The results show that the shape sensor is reliable at a maximum bending curvature of 80 mm. The average tip position error was 1.722 1.678 mm, which corresponds to 1.50 1.46% of the total length of the sensor. In this approach, the endoscopists performance may enhanced by providing using a kinetic model that provides information such as the shape of the scope, direction of the colon and forces. CONCLUSIONS: Scope guided endoscopy using FBG sensor can be successfully used to display colonoscope configuration by reconstruction of the high curvature bending and low tip position error. This Flexible, thin and almost weightless shape sensor would be a novel technique for identification of colonoscope shape. Conflict of Interest: None declared.

back-to-back crossover tandem colonoscopy study was conducted comparing FVC versus FUSE in IBD-surveillance. All subjects met national IBD surveillance guidelines inclusion criteria. The primary outcome was dysplasia miss-rate.

RESULTS: 52 subjects were recruited (23 CD, 29 UC; median age 45.0; 60% males). Mean IBD duration was 16.4 years. 104 tandem colonoscopies were conducted with 27 subjects randomized to FVC-first and 25 to FUSE-first. The overall dysplasia rate was 30.8%. The dysplasia miss rates of FVC and FUSE respectively were 71.4% and 25.0% analyzed per-lesion (P = 0.0001) and 75.0% and 25.0% analyzed per-subject (P = 0.046). FUSE identified a mean of 0.37 dysplastic lesions vs 0.12 for FVC (P = 0.007). Chromoendoscopy identified 10/28 (35.7%) of dysplastic lesions missed by white light. Targeted biopsies improved dysplasia identification (26/163, 16.0%) vs random biopsies (2/687, 0.3%, P < 0.0001). The total colonoscopy times were similar (21.2 minutes vs 19.1 minutes, P = 0.32) but withdrawal time was significantly longer (15.8 minutes vs 12.0 minutes, P = 0.03) for FUSE than FVC respectively. Correcting for withdrawal time, the mean dysplasia miss rate per subject remained significantly higher for FVC (0.83) than FUSE (0.19; P < 0.0001). Both procedures were safe and well-tolerated. CONCLUSIONS: Full Spectrum Endoscopy misses fewer dysplastic lesions and outperformed conventional forward viewing colonoscopy in inflammatory bowel disease dysplasia surveillance. Controlling for longer colonoscopy withdrawal time, dysplasia miss rate remained lower for FUSE than FVC. Conflict of Interest: None declared.


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P445: OPTIMIZATION OF PANCHROMOENDOSCOPY TECHNIQUES WITH INDIGOCARMINE AND VIDEOENDOSCOPES FOR THE DIAGNOSIS OF SMALL COLORECTAL NEOPLASM Pavel Frolov, Sergey Zaikin Regional Clinical Center of Miners’ Health Protection, Endoscopy, Leninsk-Kuznetsky, Russia

AIMS: Evaluate techniques of panchromocolonoscopy for detecting small neoplasias of the colorectal mucosa. METHODS: In a prospective clinical study included 86 patients, who underwent first-time total colonoscopy. In the control group (42 patients) videocolonoscopy was performed with 0.2% indigocarmine administered by a reusable spraying catheter through the endoscope instrument channel. In the study group (44 patients) panchromocolonoscopy was performed with the technique developed by the authors (Patent of Russian Federation No 2427311), in which indigocarmine was sprayed during intubation of the colon through a catheter attached by the rubber sleeve to the outer shell of the endoscope 150 mm from the distal end.

RESULTS: A total of 140 neoplasms detected in 86 patients (79 in the study group and 61 in the control). The average time of the study was 27.2 1.6 minutes (15–53 minutes) in the study group and 34.6 1.4 minutes (14–60 minutes) in controls, with significantly reduction of time spent in the study group (P = 0.0006). The mean volume of indigocarmine solution used in the study group was 44.6 1.8 mL (30–60 mL), in control group - 57.3 2.0 mL (30–90 mL), differed significantly (P < 0.0001). The mean number of neoplasias per patient, the number of adenomas per patient and the number of nonneoplastic lesions per patient in the study and control group were not significantly different (1.8, 1.3, 0.5 vs 1.5, 1.1, 0.2). CONCLUSIONS: A new panchromocolonoscopy technique developed by the authors allowed a quarter to reduce the duration of procedure and amount of contrast, and with less effort to perform a greater number of manipulations (polypectomy, biopsy) under colonoscopy. Conflict of Interest: None declared.

P446: AUTOFLUORECENT ENDOSCOPIC DIAGNOSTICS OF EPITHELIAL NEOPLASMS IN THE STOMACH Vladimir Duvanskiy, Mikhail Knyazev RUDN-University, Department of Endoscopy, Endoscopic and Laser Surgery, Moscow, Russia

AIMS: To find out correlation between autofluorescence (AF) coloring in gastric neoplasms and their histological structure. METHODS: 123 cases of neoplasia lesions, detected by upper endoscopy have been analyzed. The videosystem Olympus

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 Lucera СV-260 with aurofluorescence imaging (AFI) was used. AF coloring of epithelial neoplasms in the purple or green colours was noted. To find out the dependence of AF coloring of epithelial neoplasms in the stomach on their histological structure, all neoplasms were divided into 4 groups according to the Vienna Classification. Group 1 (n–12) included all types of invasive and non-invasive biopsy-proven carcinomas or high-grade dysplasia. Group 2 (n-30) included adenomatous neoplasms with dysplasia. Group 3 (n–60) included neoplasms with hyperplastic histological structure. Group 4 (n- 21) was a control group which included inflammatory neoplasms without dysplasia.

RESULTS: In Group 1 11 tumors had purple AF staining, 10 neoplasms had macroscopic structure of type 0-Is, 0-Ips. Group 2 (30 observations) - 22 neoplasms were purple and 8 green; 18 neoplasms had macroscopic type 0-IIa, 12 - type-0Is. Group 3 (60 neoplasms) - purple AF color was in 37 cases, green - in 23; By the macroscopic structure, neoplasms of type 0-Is, ps dominated and were met in 41 cases; 19 neoplasms had type 0-IIa, b. Group 4 (21 case) - 6 formations had purple AF color, 15green. Neoplasms of type 0-Is and 0-IIa dominated; they were 14; 7 were of type 0-IIb. CONCLUSIONS: Sensitivity - 0.69; Specificity - 0.71; positive prognostic value (PPV) - 0.92; negative prognostic value (NPV) 0.31. AF purple coloring of epithelial structures was found to be met more often (by 2.4 folds) comparing to the controls. Conflict of Interest: None declared.

P447: CONFOCAL LASER ENDOMICROSCOPY OF PANCREATIC SOLID TUMORS Konstantin Ryabov, Maria Rudakova Municipal Clinical Hospital No 57, Oncology, Moscow, Russia

AIMS: To evaluate possibilities of confocal laser endomicroscopy (CLE) for morphological diagnostics of pancreatic tumors. METHODS: Ultrasound complex fitted with convex ultrasound gastroscope GF-UCT-140 manufactured by firm Olympus (Japan) and system Cellvisio (Manua Kea Technologies, France) were used. In 10 minutes before examination 5.0 mL of 10% fluorescein sodium solution was injected intravenously. After detection with the help of echoendoscopy of the focal mass in the pancreas its puncture was performed by the needle 19G with pre-installed in its lumen confocal mini-probe CholangioFlexTM. Afterwards working end of mini-probe was moved 2 mm distal than needle point, and scanning of cellular elements in real-time mode was carried out. If cells suspicious for malignancy were detected, mini-probe was taken out of the needle and aspiration biopsy of the glandular tissue was performed.


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 RESULTS: Examination was performed in 22 patients (males 12, females - 9). Mean age was 68.7 years. Duration of the examination was from 20 up to 40 minutes, on the average 28.5 11.8 min. In all cases performed target puncture of the focal mass in the pancreas. According to the CLE data irregular vascular pattern with leakage of fluorescein into tumorous tissue was revealed in 18 patients. Tumorous tissue itself was presented with structureless substance with inclusion of connective tissue fibers and a group of grey small cells, of irregular shape, with large black nuclei occupying the most part of cytoplasm on its background. It allowed making provisional diagnosis of adenocarcinoma. Additionally the diagnosis was verified histologically. Complications were absent. CONCLUSIONS: CLE allows receiving significant information about morphology of pancreatic masses. It can be appropriate alternative to traditional histological examination. Conflict of Interest: None declared.

P448: A NOVEL FLUORESCEIN SPRAYING METHOD FOR ENDOSCOPIC DIAGNOSIS OF GASTROINTESTINAL NEOPLASM: PILOT STUDY Satoshi Kinoshita, Motohiko Kato, Yoko Kubosawa, Yuichiro Hirai, Yukie Sunata, Keiichiro Abe, Yoshiaki Takada, Tetsu Hirata, Shigeo Banno, Michiko Wada, Yusaku Takatori, Hideki Mori, Kaoru Takabayashi, Masahiro Kikuchi, Toshio Uraoka National Hospital Organization Tokyo Medical Center, Gastroenterology, Tokyo, Japan

AIMS: Confocal laser endomicroscopy (CLE) can visualize tissue microstructures with about thousandfold magnification in real time. To obtain an image, intravenous injection of fluorescent substance (fluorescein) is required prior to a lowpower laser illustration in CLE. Although intravenous injection of fluorescein is a standard method as safe, it rarely causes some adverse events including allergic reaction. Endoscopic spraying of fluorescein from inside of gastrointestinal tract could be an alternative method that may reduce adverse events related with systemic administration of fluorescein. So the aims of this study was to confirm feasibility of fluorescein spraying method and to clarify appropriate concentration of fluorescein in gastrointestinal tract. METHODS: This is an ex vivo study using endoscopic resection specimens. Two gastri cancer and 1 colon cancer and 1 rectal caricinoid were evaluated. Specimens were stretched on a rubber board immediately after endoscopic resection. Various concentrations of fluorescein (10%, 1.0%, 0.1%, 0.01%, 0.001% and 0.0001%) were sprayed on those specimens. We observed the specimen using confocal miniprobe (Cellvizio®, Mauna Kea Technologies). Two endoscopists reviewed all recorded images and evaluated whether crypt structure could be observed. The concentration was considered as appropriate when both endoscopists agreed that image quality was enough.


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RESULTS: Image of crypt structure was obtained in 0.01% and 0.1% of fluorescein concentration. In all resected specimens, image qualities of these concentrations were equivalent. In the higher concentrations (10%, 1.0%), background signal was too strong and in the lower concentrations (0.001%, 0.0001%), image was too dark. CONCLUSIONS: This pilot study revealed that fluoresceinspraying method seems to be feasible and 0.1% or 0.01% could be a candidate of concentrations. The further clinical study is needed to confirm feasibility and safety of this method. Conflict of Interest: None declared.

P449: DEVELOPMENT OF NOVEL CLINICAL PHOTOACOUSTIC ENDOSCOPIC PROBE TO USE IN THE GASTROINTESTINAL TRACT: DESIGN AND IMPLEMENTATION Sang Yup Lee1, Hyuk Soon Choi1, Jung Min Lee1, Byeong Kwang Choi1, Jae Min Lee1, In Kyung Yoo1, Seung Han Kim1, Eun Sun Kim1, Yoon Tae Jeen1, Hoon Jai Chun1, Hong Sik Lee1, Chang Duck Kim1, Joon-Mo Yang2, Chae Un Kim2 1

Korea University College of Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul, and 2Ulsan National Institute of Science and Technology, Department of Physics, Ulsan, Korea

AIMS: To improve diagnostic accuracy of gastrointestinal diseases, such as gastric and colorectal cancers, it is essential to develop advanced tomographic endoscopic techniques. The major limit of conventional video endoscopy is that it cannot provide such useful diagnostic information as the depth of invasion or vascular connections for advanced high-stage cancers because it solely relies on the visual inspection based on the surface-mapped camera images. At present, endoscopic ultrasound is the only available option for delineating tumor margin and visualizing surrounding structures. However, this technique is still insufficient for evaluating the mentioned diagnostic information due to the poor image contrast for soft tissues. In our current project, we have been developing a 3.0-mm diameter catheterized photoacoustic endoscopic probe with a clinically-applicable structure and imaging performance to apply to gastrointestinal tract disease diagnosis. Our key focus in designing the endoscope is to enable the probe to perform endoscopic imaging via the 3.7-mm diameter standard instrument channel of a video endoscope. METHODS: To enable cellular level visualization of suspicious tissues, we are constructing the mini-probe by adopting the optical-resolution photoacoustic imaging concept in which both the optical and acoustic beam are tightly focused in a confocal configuration. All the scanning tip and torque transmitting coil are completely sheathed by a 2.5-m long plastic catheter section.

RESULTS: We have successfully worked out an optimal system configuration that enables very uniform circumferential


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and radial scanning while conserving a high flexibility. Also, the optical and acoustic imaging performance were satisfactorily validated through a range of computer simulations and mechanical tests. Thus, it is possible to apply this technique to animal models.

CONCLUSIONS: In this presentation, we will introduce our endoscopic system and discuss clinical benefits of the proposed endoscopic design. We expect that it could provide invaluable diagnostic information based on the high-resolution and highcontrast image information. Conflict of Interest: None declared.

P450: NOVEL PROBE BASED QUANTATIVE IMAGE OF MITOCHONDRIA USING MULTIPHOTON MICROSCOPY IN LIVE COLON CANCER TISSUE Eun Sun Kim, Sang Yup Lee, Jung Min Lee, Byeong Kwang Choi, In Kyung Yoo, Seung Han Kim, Jae Min Lee, Hyuk Soon Choi, Bora Keum, Yoon Tae Jeen, Hoon Jai Chun, Hong Sik Lee, Chang Duck Kim Korea University Anam Hospital, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul, Korea

AIMS: Multiphoton endomicroscopy is the recently updated technique for endoscopy and virtual image and optical sectioning. However optimized probe has not been established for multiphoton endomicroscopic image. Therefore we developed novel probe for mitochondria and applied for colon neoplasm tissues. In cancer cell, abnormally increased mitochondrial replication is related mitochondrial dysfunction and Warburg effect.

METHODS: We used newly developed multiphoton probe for mitochondria imaging which are made using benzofuran derivative (BFP, maximal multiphoton fluorescence at 570 nm, Figure 1). Fresh mucosal tissues of colonic adenoma and adenocarcinoma were obtained from endoscopic biopsy. Multiphoton probe BFP for mitochondria was stained for tissues and imaging performed using multiphoton microscopy.

RESULTS: BFP shows high enhancement factor upon binding mitochondria, good selectivity, cell permeability, and can readily detect mitochondria in human tissues by multiphoton microscopy. Mitochondria were detected in human colon mucosa tissues. Calculated mitochondria area were increased in adenocarcinoma tissues compared to normal mucosal tissue. CONCLUSIONS: Newly developed multiphoton probe for mitochondria are usable to image human live colon tissues. Conflict of Interest: None declared.

P451: SPYGLASS DIRECT VISUALIZATION SYSTEM VS DIRECT PERORAL CHOLANGIOSCOPY USING BY A MULIBENDING ULTRASLIM ENDOSCOPE AS A SINGLE-OPERATOR PERORAL CHOLANGIOSCOPY FOR MANAGING BILIARY LESIONS Yun Nah Lee1, Jong Ho Moon1, Hyun Jong Choi1, Hee Kyung Kim2, Moon Han Choi1, Tae Hoon Lee1, Sang-Woo Cha1, Young Deok Cho1, Sang-Heum Park1 1

Soonchunhyang University School of Medicine, Digestive Disease Center and Research Institute, Department of Internal Medicine, and 2Soonchunhyang University School of Medicine, Department of Pathology, Bucheon and Seoul, Korea

AIMS: Single-operator peroral cholangioscopy (POC) has been a new modality for diagnosis and treatment for various bile duct (BD) diseases. Up to date, SpyGlass direct visualization system (SpyGlass) and direct POC (DPOC) using ultra-slim endoscope have been used as a single operator POCs. However, there is no study to comparing two systems. In this study, we prospectively compared the procedure success rate of POC using SpyGlass and DPOC for diagnosis and treatment of BD lesions. METHODS: A total of 21 patients with BD lesions (diameter of CBD ≥8 mm) requiring evaluation or treatment using POC were enrolled prospectively. All patients received POC using SpyGlass and mulibending ultraslim endoscope for DPOC. According to the presence of obstructive lesion, all patients were classified as obstructive type (8 patients) or non-obstructive type (13 patients), respectively. Technical and procedural success defined as abilities to visualize bifurcation / obstructive lesions and visualize target lesions / stone fragmentation, respectively.

RESULTS: There was no significant differences between the SpyGlass and DPOC in technical success rates (100% vs 95.2%, P = 0.485) and overall procedural success rate (71.4 % vs 90.5%, P = 0.119). The procedural success rates of SpyGlass and DPOC were not different in 8 obstructive type (100% vs 87.5%, P = 0.5). In 13 non-obstructive type, DPOC showed significantly higher procedural success rate (53.8% vs 92.3%, P = 0.037). There was no significant difference between SpyGlass and DPOC groups in the success rates of targeted biopsy (80% vs 100%, P = 0.385) and stone lithotripsy (100% vs 75%, P = 0.5), respectively. CONCLUSIONS: Both SpyGlass and DPOC demonstrated high technical success rates in patients with biliary lesions having dilated BD, but DPOC showed a higher procedural success for non-obstructive BD lesion. The POC using SpyGlass or DPOC according to the characteristics of BD lesion can be considered to improve the success rate of managing biliary lesions. Conflict of Interest: None declared.




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P452: EARLY GASTRIC CANCER MULTIMODAL ENDOSCOPIC DIAGNOSTICS: VALUE OF CONFOCAL LASER ENDOMICROSCOPY AND ENDOCYTOSCOPY

P453: FRONTAL-VIEW VS FULL-SPECTRUM ENDOSCOPY (FUSE): VISUALIZATION OF GREATER PAPILLA AND DETECTION OF AMPULLARY LESIONS

Sergey Pirogov1, Viktor Sokolov1, Andrey Kaprin2, Dmitry Sokolov1, Elena Karpova1, Dmitry Sukhin1, Nadejda Volchenko3, Andrey Ryabov4, Vladimir Khomyakov4, Vadim Cheremisov4

Marina Lordello Passos, Vitor Ottoboni Brunaldi, Rodrigo Silva Paula Rocha, Mauricio Kazuyoshi Minata, Ossamu Okazaki, Aureo Augusto Almeida Delgado, Gustavo Luis Rodela Silva, Edson Ide, Elisa Ryoka Baba, Eduardo ~es Horneaux de Moura Guimara

1

P.A. Herzen Moscow Oncology Research Institute, Endoscopy, Moscow, Russia, 2P.A. Herzen Moscow Oncology Research Institute, Moscow, Russia, 3P.A. Herzen Moscow Oncology Research Institute, Pathology, Moscow, Russia and 4P.A. Herzen Moscow Oncology Research Institute, Thoracic & Abdominal Surgery, Moscow, Russia

AIMS: Gastric cancer is a common problem in Russia, more than 33000 new cases of gastric cancer detected per year in our country, but not more than in 4% patients gastric cancer diagnosed at early stage. So, the main aim of our study is to improve quality of early gastric cancer (EGC) diagnostics by development of multimodal endoscopic approach, including new “optical biopsy” methods - confocal laser endomicroscopy and endocytoscopy. METHODS: In P.A. Herzen Moscow Cancer Research Institute in 2012 - 2016 we have detected 394 cases of EGC. In majority of cases we have performed multimodal endoscopic diagnostic approach, including high-definition white-light endoscopy (WLIHD), narrow-band imaging (NBI), narrow-band magnifying endoscopy (NBI-ME) autofluorescence endoscopy (AFI), endoscopic ultrasonography (EUS) and ultra-high magnification endoscopy: confocal laser endomicroscopy (CLE) and endocytoscopy (EC). For CLE we have used endoscope-based system Pentax ISC-1000 and probe-based system Cellvizio with intravenous Fluorescein sodium 5 mL. For EC Olympus XEC-300 endocytoscope prototype with 9570 magnification and 1% methylene blue dye were used. All methods were used consecutively.

RESULTS: According to our data, WLI-HD showed only 71.4% accuracy in EGC diagnosctics, AFI provided high (86.3%) sensitivity, but only 47.4% specificity, NBI was more accurate 82% with criteria of distorted and absent pit-pattern, NBI-ME showed 86% sensitivity with use of VS-classification. EUS provided 73% accuracy in predicting tumor invasion depth, so we have used additionally forceps-traction criteria. The most accurate (92.1%) method in EGC diagnostics was CLE, but it has limited to 500 um field of view. EC showed 73.4% accuracy with methylene blue dye and it is unclear, why some tumor cells remain undyed.

CONCLUSIONS: The most applicable multimodal endoscopic

Faculty of Medicine of University of Sao Paulo, ~ o Paulo, Gastroenterology Department - Endoscopy Unit, Sa Brazil

AIMS: Precise diagnosis of early ampullary lesions depends on a good visualization of the Greater Papilla. The common frontal-view gastroscope has high accuracy rates for diseases of upper gastrointestinal tract (UGIT). However, small lesions on blind spots of UGIT such as anal side of pyloric ring and Vater’s Ampulla may go unnoticed when using typical gastroscope. The aim of this study was to test diagnostic capability according to the Greater Papilla (GP) visualization with a new endoscopy platform named FUSE. This platform has a high definition gastroscope attached to a left-sided camera and LED, which raises the range of view from 170° to 245°. METHODS: This single-center study included consecutive patients referenced for diagnostic esophagogastroduodenoscopy from April to July, 2016. Exclusion criteria were patients older than 85 years and altered anatomy due to prior surgical procedure. The descending portion of the duodenum was accessed with frontal-view and visualization of the GP categorized as: Complete (included all ampulla without any blind spot, including proximal and distal fold); Incomplete; or Not Visualized. Then, the left-sided camera was turned on and the same categorization was performed. When a lesion was detected, biopsy was done.

RESULTS: Sixty-seven patients were enrolled. Overall mean age was 50.1 years. The rates of Complete Visualization of GP were 8.96% and 85.07% (P < 0.00025) with frontal and side-view respectively. Not Visualization were 28.36% and 2.99% (P < 0.00025). Three patients presented ampullary lesions and histology confirmed diagnosis of adenoma. Among them, 2 were Familial Adenomatous Polyposis patients. CONCLUSIONS: FUSE improved significantly the diagnostic yield of EGD for ampullary lesions. More studies are needed to assess the impact on outcomes and cost-effectiveness of this method. [Results]. Conflict of Interest: None declared.

approach in EGC diagonostics is consecutive use of WLI-HD endoscopy, NBI, NBI-ME and EUS with subsequent CLE of any detected lesion. EC as EGC diagnostic method need further investigation. Conflict of Interest: None declared.


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P454: THE EFFECT OF A FLEXIBLE 3D ENDOSCOPE ON LEARNING CURVE OF ENDOSCOPIC SUBMUCOSAL DISSECTION: A BENCH TOP EX-VIVO STUDY

Conflict of Interest: Philip Chiu is chairman of Asian NBI Group, which received sponsorship from Olympus Co Ltd.

Baldwin Yeung1, Xianfeng Xia2, Candice Lam2, Philip Chiu2

P455: DETECTION OF NEOPLASIA IN BARRETT´S ESOPHAGUS (BE) WITH IMAGE ENHANCEMENT USING OE - AN EARLY EXPERIENCE

1

West of Scotland Regional UGI Cancer Resection Unit, Glasgow Royal Infirmary, Glasgow, UK, Glasgrow, UK and 2 Chinese University of Hong Kong, Dept of Surgery, Hong Kong, China

AIMS: Endoscopic submucosal dissection (ESD) has steep learning curve. The lack of depth perception may contribute to its difficulty. This study assess the effect of 3D endoscope on the learning curve of gastric ESD. METHODS: This is a prospective preclinical bench study using 3D endoscope to compare performance of ESD between experienced endoscopist and novice. The participants included an endoscopist with more than 1000 endoscopic procedures but little experience in ESD and a novice with total endoscopic experience of less than 50. The performance of gastric ESD was standardized in an ex-vivo porcine model using a prototype 3D endoscope (Olympus R&D, Tokyo, Japan). Each participant performed 8 ESD over greater curvature using Dual knife jet. The time to complete ESD, occurrence of perforation and enbloc resection rate were recorded. Resected specimens were digitalized and surface area was calculated using GIMP 2.8 image analysis software. Descriptive statistics and non-parametric analysis was performed using IBM SPSS v22.

RESULTS: En bloc resection was achieved in all ESD procedures without perforation. The median resected area by experienced endoscopist was 3.8 cm2 (min: 1.04 cm2 max: 7.9 cm2), with no significantly difference from that achieved by novice with the median area of 3.3 cm2 (min: 0.86 cm2 max: 8.25 cm2) (P = 0.87). The median operative time corrected for surface area for the experienced endoscopist was 197.9s/cm2 (min: 60.9s/cm2 max: 1897.4s/cm2), which was significantly lower than that of the novice endoscopist (median resection speed = 434.7s/cm2 (min: 217.2s/cm2 max: 1544.2s/cm2)) (P = 0.05). For both participants, resection speed plateaued after third ESD procedure (learning curve y = 1183.4x 0.807 (R2=0.6927)). CONCLUSIONS: This preclinical bench study illustrated that the use of prototype 3D endoscope may shorten the learning curve for ESD. 3D images improved depth perception for the endoscopist and resulted in better en-bloc resection as well as preventing perforation. This will especially be useful for low experience endoscopists to master ESD.

Sneha John1,2, Dianne Jones1, Helmut Neumann3 1 Logan Hospital, Gastroenterology, Logan, Australia, 2Gold Coast University Hospital, Gastroenterology, Southport, Australia and 3University Hospital Mainz, Gastroenterology, Mainz, Germany

AIMS: Current surveillance protocols for BE recommend quadrant biopsies every 2 cm. Multiple biopsies carry a risk of sampling error and are time consuming and costly. Targeted biopsies with image enhancement have been proposed as potential alternatives. The PIVI statement states that technology for BE surveillance should achieve sensitivity >90% and a negative predictive value of 98% or greater. Most technologies in this area have struggled to achieve this. OE is a new technology that combines the analysis of microvascular pattern using band limited light with digital chromo endoscopy. In OE1 mode, spectral transmission utilises the peak wavelength of the haemoglobin absorption spectrum. OE2 mode adds the longer wavelength of red light allowing more natural and brighter illumination. It is expected that the combination will enhance detection and characterisation of neoplasia. We aimed to assess the use of OE in detecting dysplasia in BE. METHODS: 14 patients with BE were assessed as part of the study.8 of these individuals had established long segment disease with biannual surveillance. No patient had previously been diagnosed with dysplasia or undergone endoscopic therapy. One patient had cellular atypia associated with active inflammation reported previously. Barrett´s mucosa was examined with high definition white light followed by OE. Biopsies identifying any dysplasia were reviewed by 2 pathologists.

RESULTS: We did not discover visible abnormalities or dysplasia on endoscopy or pathology in 12 of the 14 cases. In one individual with long segment BE an area of focal high grade dysplasia was predicted with OE and confirmed by 2 pathologists. Another had ulceration and reactive changes on OE and confirmed with pathology. Negative predictive value for dysplasia was 100% in our series. CONCLUSIONS: Our early experience using OE in Barrett´s suggests that this new technology is promising in its ability to

Frontal View Mean Age 50.1

n (%)

Side View

Male

Female

Complete

Incomplete

Not Visualized

Complete

Incomplete

Not Visualized

27 (40.3%)

40 (59.7%)

6 (8.96%)

42 (62.69%)

19 (28.36%)

57 (85.07%)

8 (11.94%)

2 (2.99%)


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 accurately detect neoplasia. Further prospective studies are required to assess it´s utilisation in clinical practice. Conflict of Interest: None declared.

ENDOSCOPIC TECHNOLOGY: ENDOSCOPY: NEW THERAPEUTIC TECHNOLOGY P456: FIRST CHINESE HUMAN GASTRIC PERORAL ENDOSCOPIC MYOTOMY FOR DIABETIC GASTROPARESIS Xing Zhang, Rui Li, Dong Tao Shi, De Qing Zhang, Wei Chang Chen The First Affiliated Hospital of Soochow University, Department of Gastroenterology, Suzhou, China

AIMS: Diabetic gastroparesis is a chronic complication of diabetes characterized. The delayed gastric emptying can significantly affect digestion and absorption of food, at the same time, due to the influence of absorption of oral drugs, it can also interfere with the treatment of diabetes. There is currently no effective treatment of the diabetic gastroparesis, this article aims to introduce a new technology which may be effective in the management of DGP. METHODS: By reporting a case of treating the diabetic gastroparesis by gastric peroral endoscopic myotomy, this article is in the hope of granting some hints to help clinical management of DGP.

RESULTS: The patient, in this report, tolerated a regular diet and was nearly symptom free and the self-assessed GCSI had decreased to a total score of 6 after the operation. CONCLUSIONS: Endoscopic pyloromyotomy has exciting potential to be at the forefront in the management of DGP. Conflict of Interest: None declared.


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METHODS: Two women 71 and 61 years old underwent ESD for gastric SMT. The diameter of the tumors was 35 mm and 51 mm, both originating from the muscularis mucosae with intraluminal type of growth and were localized in the distal body and antrum. We began ESD with the semicircular mucosal incision around the proximal part of SMT. Step-by-step dissection of the tumor was performed with IT knife and Triangle Knife, keeping the distal half of mucosal surface and mucosa, covering the tumor, intact. So, the distinctive feature of the operation was the preservation of mucous flap and reposition it to the postoperative defect without special fixation. All patients received proton pump inhibitors. Control EGD was performed at 2, 5 and 30 postoperative day.

RESULTS: Both operations were successfully completed without complications. The duration of interventions was 100 and 240 minutes. The diameter of postoperative defects was 45 and 55 mm, both were completely covered with the saved mucous flap. During the control EGD on day 2 the flaps were displaced with the purpose of detailed inspection of the bottom of the postoperative wounds. Preventive endoscopic hemostasis was not performed. On day 5 after the operation mucous flaps were tightly fixed to the bottom of the postoperative defects; on day 30 postoperative wounds completely healed. Patients left the hospital without any complaints. Pathomorphological and immunohistochemistry examination revealed GIST of the stomach with low malignant potential. CONCLUSIONS: ESD of large gastric GISTs with coating the wound´s surface by retained mucous flap could reduce the risk of postoperative bleeding, delayed perforation and accelerate healing of post-ESD defect. Conflict of Interest: None declared.

P458: EFFECTIVE AND SAFE TECHNOLOGY OF ENDOSCOPIC MUCOSAL RESECTION FOR FLAT COLORECTAL NEOPLASIA Sergey Zaikin, Pavel Frolov

P457V: PLAIN TRICKS WITH A SERIOUS SIGHT: COATING THE WOUND´S SURFACE AFTER ENDOSCOPIC DISSECTION OF LARGE GASTROINTESTINAL STROMAL TUMORS OF THE STOMACH WITH RETAINED MUCOUS FLAP Roman Plakhov, Evgeny Fedorov, Evgeny Gorbachev, Stanislav Budzinsky, Andrey Biryukov Research Educational Center of Abdominal Surgery & Endoscopy, Pirogov Russian National Research Medical University, Moscow University Hospital N31, Moscow, Russia

AIMS: Prevention of postoperative bleeding and perforation are the main tasks after endoscopic submucosal dissection (ESD) both for epithelial neoplasia and submucosal tumors (SMT). However ESD for SMT opens opportunity of keeping the mucosal membrane covering the tumor, alive.

Regional Clinical Center of Miners’ Health Protection, Endoscopy, Leninsk-Kuznetsky, Russia

AIMS: To examine the efficacy of device developed by authors for endoscopic mucosal resection (EMR) for flat neoplasia of the colon. METHODS: In a prospective clinical study 130 neoplasia (8.2 1.31 mm) 0-IIa type in basic group were removed by EMR with device developed by authors (Copyright Patent RF No 2308902), in the control group removed the 128 neoplasia (7.7 1, 29 mm) 0-IIa type using the standard snares.

RESULTS: A total of 152 patients with 258 neoplasia histologically diagnosed 241 (93.4%) tubular adenoma, 12 (4.7%) tubularvillous and 5 (1.9%) villous adenomas. The area of resected mucosa: basic group - 89.4 27.55 mm2; control group 20.6 10.66 mm2 (P < 0.001). Proper muscle plate of mucous verified in 94.6% of cases the basic group and in 40.6% - the


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control (P < 0.025). The high grade dysplasia was detected in 10 (7.7%) cases of adenomas of the basic group, in 3 (2.3%) adenomas from the control group (P < 0.05). There were 5 (1.9%) complications such as a primary bleeding: 1 (0.8%, n = 130) case in the basic group, 4 (3.1%, n = 128) in the control group. Bleeding was treated by endoscopic hemoclipping. 6 months after EMR detected 3 cases of recurrence of adenomas - only in the control group (5.8%, n = 52).

CONCLUSIONS: EMR by device developed by authors is effective and safe for small flat neoplasias of the colon. Conflict of Interest: None declared.

P459: GASTRIC PERFORATION FOLLOWING INTRAGASTRIC BALLOON INSERTION: COMBINED ENDOSCOPIC AND LAPAROSCOPIC APPROACH FOR MANAGEMENT: CASE SERIES AND REVIEW OF LITERATURE Bassem Abou Hussein, Ali Khammas, Ali Al Ani, Abeer Swaleh, Sameer Al Awadhi, Yousif El Tayyeb, Alya AlMazrouei, Faisal Badri Rashid Hospital - Dubai Health Authority, Dubai, United Arab Emirates

AIMS: Obesity is a serious disease, with substantial morbidity and mortality. The endoscopic placement of an intragastric balloon (IGB) in association with a low-calorie diet is an option for the treatment of obesity. IGB complications include dislocation of the balloon causing intestinal obstruction, upper gastro-intestinal bleeding and perforation, especially during balloon insertion or removal. Our work aims at decreasing the morbidity of open laparotomy in the management of such gastric perforations. METHODS: We report three cases of gastric perforation following IGB insertion that needed surgical intervention. Decision was made to treat them with a minimally invasive combined endoscopic and laparoscopic approach to decrease postoperative morbidity.

RESULTS: All patients were successfully treated by a minimally invasive approach with less morbidity than the conventional open laparotomy. CONCLUSIONS: Gastric perforation should be suspected in any patient with IGB who presents with an acute abdomen. This can be managed with a minimal invasive approach. Conflict of Interest: None declared.

P460: EFFECTIVENESS OF IRREVERSIBLE ELECTROPORATION ABLATION: A COMPARATIVE STUDY IN COLON CANCER ANIMAL MODEL Jung Min Lee1, Hyuk Soon Choi1, Hoon Jai Chun1, In Kyung Yoo1, Jae Min Lee1, Seung Han Kim1, Eun Sun Kim1, Bora Keum1, Yoon Tae Jeen1, Chang Duck Kim1, Joo Young Kim2 1

Korea University Anam Hospital, Divison of Gastroenterology, and 2Korea University Anam Hospital, Department of Pathology, Seoul, Korea

AIMS: Irreversible electroporation (IRE) is a promising novel technique for the ablation of tumor. IRE has an advantage over other ablation technique in its mechanism to remove undesired cells by affecting the cell membrane without thermally destructing surrounding blood vessels, nerves. There have been recent concerns regarding the potential use of IRE as an ablative modality. The aim of this study was to evaluate the effectiveness of IRE ablation according to therapeutic method in colon cancer animal model. METHODS: Male nude mice (6 weeks old) were introduced. Caco2 cells (ATCC) were each visually injected into both flakes. We performed in vivo IRE procedures in the tumors of nude mouse model. Electrical pulses were applied to the tumor of nude mice using a DC generator at 1–2 kV/cm amplitude, 100– 200 pulses, 100~300 ㎲ length. A group received early ablation (0, 7 day), and the other group received continuous ablation (0, 7, 14, and 21 days). We compared the size of tumors between control and IRE ablation group.

RESULTS: The size of IRE ablative tumors significantly decreased comparing with the control. (P = 0.005) But there was no significant difference between early ablation group and continuous ablation group. (P = 0.972) There was complete cell death within the IRE lesions without intervening live cells. Histologically, in each group, the IRE ablative tumors were nonviable, with a persistent tumor nodule replaced fibrosis. The tissue with H&E stain and Tunnel assay showed apoptotic cell death in the 1 days after IRE ablation. The tissues after 24 h IRE ablation showed diffuse necrotic cell death. CONCLUSIONS: The present study demonstrated that IRE ablated colon cancer tissue very effectively through the induction of cellular apoptosis in the early stage. This study suggests that IRE is the potential use of IRE in colon cancer. Conflict of Interest: None declared.




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P461: LAPAROSCOPIC AND ENDOSCOPIC COOPERATIVE SURGERY FOR GASTRIC SUBMUCOSAL TUMORS

P462: GASTRIC ESD UNDER ADJUSTABLE COUNTERTRACTION USING A NOVEL OVERTUBE WITH BUILTIN SIDE CHANNELΔ

Toshiaki Hirasawa, Naoki Hiki, Ken Namikawa, Kaoru Nakano, Souya Nunobe, Yorimasa Yamamoto, Junko Fujisaki, Takeshi Sano

Motohiko Kato1, Shigeo Banno1, Takuya Yamada2, Toshio Uraoka1, Kiyokazu Nakajima3,4

Cancer Institute Hospital Ariake, Gastroenterology Center, Tokyo, Japan

AIMS: This study aimed to introduce laparoscopic and endoscopic cooperative surgery (LECS) for gastric wedge resection in intragastric-type submucosal tumors (SMTs). METHODS: We retrospectively analyzed data from 123 patients [60 men and 63 women; mean age, 58 (range, 26– 81) years] who underwent LECS for the resection of intragastrictype SMT at the Cancer Institute Hospital Ariake, Tokyo, between June 2006 and February 2016. To determine the precise resection line, mucosal and submucosal layers around the tumor were circumferentially dissected using endoscopic submucosal dissection (ESD) via intraluminal endoscopy. An artificial perforation was then made by the endoscopist using a needle knife. Subsequently, the seromuscular layer was laparoscopically dissected along the incision line by ESD. After a complete tumor resection, a closure of the defect in the gastric wall was performed using a standard endoscopic stapling device.

RESULTS: The mean tumor size was 3.5 cm (range, 1.5– 6.5 cm). All surgical margins were clear. Histopathologic examination revealed gastrointestinal stromal tumor (n = 86), leiomyoma (n = 15), schwannoma (n = 11), ectopic pancreas (n = 5), carcinoid (n = 4), and, cyst (n = 2). The mean operation time was 186 min, and the mean estimated blood loss was 14 mL. In 117 cases, the LECS procedure was successful in resecting the gastric SMT. The remaining six cases were converted to open surgery or laparoscopic proximal gastrectomy because an extensive resection of more than half of the circumference of the esophagogastric junction (EGJ) was required. Among the converted cases, anastomotic leakage occurred in two cases and anastomotic stenosis occurred in one. CONCLUSIONS: LECS is useful for resecting of gastric SMT, although extensive resection around the EGJ is not feasible. Conflict of Interest: None declared.

1 National Hospital Organization Tokyo Medical Center, Department of Gastroenterology, Tokyo, 2National Hospital Organization Osaka Medical Center, Department of Gastroenterology, Osaka, 3Osaka University Graduate School of Medicine, Department of Gastroenterological Surgery, Suita, and 4Global Center for Medical Engineering and Informatics, Osaka University, Division of Next Generation Endoscopic Intervention, Global Center for Medical Engineering and Informatics, Suita, Japan

AIMS: Obtaining effective counter-traction is always a key to success for endoscopic submucosal dissection (ESD). Recently we developed “Endotornado,” a novel overtube with built-in side channel through which we can use standard flexible devices to obtain counter-traction. The aim of this study was to assess feasibility of gastric ESD using this overtube. METHODS: This is an animal experiment using 2 living pigs. Ten hypothetical lesions with a size of 20 mm were created in the greater curvature of upper stomach in each pig (total 20 lesions). A novice endoscopist whose experience of gastric ESD was less than 10, attempted ESD with vs without Endotornado (traction ESD vs conventional ESD). Traction ESD procedure was as follows: At first, mucosal incision was made around the lesion. Next, an endoscopic clip was deployed on the oral edge of the lesion. Then Endotornado was introduced orally into the esophagus and the clip was captured by a snare forceps inserted through the side channel of Endotornado. The submucosal dissection was performed under counter-traction adjusted by the snare. Procedure time for submucosal dissection, total procedure time, en bloc resection rate, and adverse events rate were compared between traction ESD (n = 10) and conventional ESD group (n = 10).

RESULTS: Appropriate submucosal exposure was obtained in traction ESD group. Although there was no significant difference in total procedure time, significant reduction of time for submucosal dissection was observed in traction ESD group (235 99 sec vs 778 353 sec, P = 0.0107). There was no case with complications due to neither ESD procedure itself nor Endotornado. Conclusions: This novel overtube accomplished significant reduction of dissection time by archiving robust and adjustable counter-traction. It may be helpful to standardize complex endoscopic procedures especially for less experienced endoscopists. Conflict of Interest: None declared.


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P463V: AN INNOVATIVE LAPAROSCOPIC AND ENDOSCOPIC COOPERATIVE SURGERY (LECS) TECHNIQUE IN ANIMAL MODEL Flavio Hiroshi Ananias Morita, Christiano Makoto Sakai, Julio Cesar Martins Aquino, Eduardo Guimaraes Hourneaux de Moura, Paulo Sakai University of Sao Paulo Medical School, Gastroenterological ~ o Paulo, Brazil Endoscopy, Sa

AIMS: LECS (Laparopic and Endoscopic Cooperative Surgery) is a minimally invasive surgery technique, which combines the advantages of laparoscopy and endoscopy in a single procedure. Resection of full thickness of the organ wall using the minimum required margin can be performed by LECS. Its current indications are for resections of submucosal lesions and early adenocarcinoma. METHODS: We have standardized a new LECS technique in the stomach of an animal model. The area including the lesion to be resected is demarcated combining the endoscopic and laparoscopic view. Submucosal injection is performed by endoscopy around the lesion to avoid mucosal damage during the laparoscopic dissection. A ring of seromuscular layer external to the marking is resected in order to make easier the wall invagination with the lesion. An encircling suture involving only the mucosa is applied aiming a purse string suture and before tying it the wall to be resected is pushed down and a snare or an endoloop is applied. Afterwards the defect in the seromuscular layer is closed with a continuous suture. The resection of the lesion is concluded by the mucosa section using a polypectomy snare or endoknife. The opening in the gastric mucosa may be closed applying endoclipes. The resected sample is orally removed.

RESULTS: Hybrid laparoendoscopic full-thickness resection without bacterial contamination and tumor seeding of the abdominal cavity.

CONCLUSIONS: This new LECS technique might solve many issues related to the combined resections described up to now by a simple and widely reproducible way. Conflict of Interest: None declared.


P464: MECHANISM STUDY ON EFFECT OF IRREVERSIBLE ELECTROPORATION IN COLON CANCER CELLS: DETECTION OF NUCLEUS AND MITOCHONDRIA BY MULTIPHOTON MICROSCOPY IMAGING Sang Yup Lee, Jung Min Lee, Byeong Kwang Choi, In Kyung Yoo, Seung Han Kim, Jae Min Lee, Hyuk Soon Choi, Eun Sun Kim, Bora Keum, Yoon Tae Jeen, Hoon Jai Chun, Hong Sik Lee, Chang Duck Kim Korea University College of Medicine, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Seoul, Korea

AIMS: Irreversible electroporation (IRE) is a promising novel technique for tumor ablation using energy current pulses. IRE can effectively remove unwanted cells without thermally damaging surrounding tissues. For reliable and quick assessment of the response to IRE ablation in colon cancer, we used multi-photon (MP) probes. METHODS: Colon cancer cell lines, normal colon mucosa and colon neoplasm tissues obtained during colonoscopic biopsy were stained with multi-photon (MP) probes, that is ABI-Nu for nucleus and PMT for mitochondria. We evaluated the feasibility of using multiphoton microscopy (MPM) to observe IRE responses. First, the responses of colon cancer cells and tissues to IRE were investigated using MPM. Electrical pulses were administered with a Harvard apparatus, and the changes in the intensity of the nucleus and mitochondria were observed over time. Second, to assess apoptosis, colon cancer cells were stained with the fluorescent dye Annexin-V or propidium iodide (PI) after applying electroporation at the same energy used earlier.

RESULTS: MPM images of cancer cells stained with MP probes revealed that ABI-Nu stained quicker after IRE ablation. At the tissue level, nuclear staining was present earlier and was more prominent after IRE was applied. In addition, IRE had a relatively stronger effect on cancer tissue than on normal tissue. We obtained MPM images for each tissue slice, including four MP images for every 150 sections at a depth of 90–150 μm along the z-direction. Using the same electroporation energy, staining was positive for Annexin V and PI, providing the evidence of apoptosis. CONCLUSIONS: We observed using MPM that nuclear staining occurred quickly due to increased cell membrane permeability and bleb was formed after electric pulse exposure. These results are expected to challenge the understanding of the permeability process after IRE by providing the real-time images. This MP probe protocol would dramatically increase the accuracy of diagnostic techniques by providing in vivo cell images. Conflict of Interest: None declared.




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P465: IATROGENIC INJURIES AND STRICTURES OF THE BILE DUCTS. MODERN METHODS OF TREATMENT

P466: ENDOSCOPIC STENT INSERTIONT IN THE MANAGMENT OF POST SLEEVE GASTRECTOMY LEAKS: RASHID HOSPITAL EXPERIENCE

Mikhail Korolev, Ruben Avanesyan, Leonid Fedotov, Georgij Lepekhin, Tigran Amirkhanyan

Bassem Abou Hussein, Ali Khammas, Sameer Al Awadhi, Alya Al-Mzarouei, Faisal Badri

Saint Petersburg State Pediatric Medical University, Saint Petersburg, Russia

Rashid Hospital - Dubai Health Authority, Dubai, United Arab Emirates

AIMS: to show the effectiveness of combined miniinvasive technologies in the treatment of early complications and late consequences of damage to the bile ducts.

AIMS: Staple-line leak after sleeve gastrectomy is a challenging complication with difficult management. With advancement of endoscopy, self-expanding covered stents are more commonly used. We to determine the efficacy and safety of nonmigratory stents after sleeve gastrectomy leak.

METHODS: Minimally invasive surgery under combined (ultrasonic, endoscopic, X-ray) control performed for 136 patients with iatrogenic injuries of the bile ducts. In the study group there were 49 men, 87 women. The average age of the men was 47.3 years, women 64.7.

RESULTS: Patients were divided into 2 groups: 1st ‒ patients with early complications of operations on the bile duct, 2nd patients with late consequences of iatrogenic damage. In the early complications group we included patients with intersection, clipping and ligation of the bile duct. Patients with stricture due to thermal damage, stricture biliary-biliary- and biliaryenteric anastomosis were taken to the late consequences of iatrogenic damage. At the intersection of the duct patients underwent combined intervention aimed at restoring the integrity of the duct using percutaneous and endoscopic manipulation, the purpose of which was to provide guidewire through the damaged area and frame drainage of the duct. When clipping or ligation of the duct, main task of the minimally invasive manipulation is conducting of the guidewire through the stricture, the balloon dilatation, frame drainage duct. Strictures of the bile ducts after reconstructive surgery, thermal damage method are identical. You have to pass the stricture, perform dilation and frame to provide drainage ducts up to 2 years with periodic change of drainage, with a gradual extension of the diameter. Sometimes the nitinol self-expanding stent were used. The mortality was 0.74%.

CONCLUSIONS: Each case connected with damage or stricture of the bile duct requires an individual approach. Based on our experience in the treatment of this category of patients, we believe that the combination of minimally invasive techniques is a priority in the treatment of injuries of the bile ducts. Conflict of Interest: None declared.

METHODS: From January 2014 till June 2016, 19 patients presented to Rashid Hospital with post sleeve gastrectomy leaks (5 from our hospital and 14 from other hospitals). Leaks were assessed by CT scan and endoscopy. Treatment included NPO, TPN, Endoscopic Stent insertion +/- CT-guided or laparoscopic draiange of big collections if present.

RESULTS: Patients were followed up as inpatient and outpatient. Two patients were lost for followup after discharge. 17 patient improved well, tolerated the procedure and were discharged in a mean of 7 days after the stenting. No cases of migration or major complication. the main side effect was prolonged nausea and vomiting (12 patients). Stents were removed after average of six weeks. CONCLUSIONS: From this study, we conclude that endoscopic stenting is a safe and effective tool in post sleeve gastrectomy leaks. Patients may need co-managment with CTguided or laparoscopic drainage if large collections were found. Further studies with larger number should be considered to emphasize these results. Conflict of Interest: None declared.

P467V: TWO STAGE TUNNELING ESD FOR CIRCUMFERENTIAL GIANT RECTAL LATERAL SPREADING TUMOR (LST) Amol Bapaye, Nachiket Dubale, Mahesh Mahadik, Siva Sankar Reddy Gangireddy, Tarun Bharadwaj, Rajendra Pujari, Rahul Lokhande Deenanath Mangeshkar Hospital, Shivanand Desai Center for Digestive Disorders, Pune, India

AIMS: Large rectal lateral spreading tumors (LST) although often benign, may harbor dysplasia or early malignancy within. Endoscopic resection techniques include endoscopic submucosal dissection (ESD) or piecemeal endoscopic mucosal resection (EMR-P). Enbloc resection by ESD is preferable in order to enable optimal histopathology but is often difficult due to large size and technical difficulty. Piecemeal EMR is therefore often employed, but remains suboptimal in terms of resection margins and final histopathological assessment.


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We demonstrate a simplified two-stage tunneling ESD for giant circumferential rectal lateral spreading tumor to enable complete resection.

METHODS: 58-year female presented with diarrhea and occasional per rectal bleeding. Colonoscopy revealed a large circumferential lateral spreading tumor of 13 cm in length in the rectum starting at anal verge. ESD was planned. The lesion was resected in two stages 48-h apart. A tunneling ESD technique was performed. Mucosal incision was taken at the anorectal junction on posterior wall and beyond proximal extent of the lesion. Submucosal (SM) dissection was performed and lesion was lifted from SM layer in entire extent until the endoscope exited from the proximal mucosal incision. The lateral margins were then dissected and the lesion was divided longitudinally on both sides to complete the resection. 48-h later, a similar technique was used anteriorly to complete the dissection.

RESULTS: Post-operative course was uneventful. Follow up at six weeks revealed complete healing and no stricture formation. Follow up at six months and one year revealed no recurrence.

CONCLUSIONS: Two stage tunneling ESD technique is safe and enables complete resection of giant circumferential rectal lateral spreading tumors. The technique may enable faster ESD and reduced risk of recurrence. Conflict of Interest: None declared.

P468: EVALUATION OF BAND LIGATION FOR THE MANAGEMENT OF GASTRIC VARICES: 1 YEAR EXPERIENCE Waseem Seleem, Amr Hanafy Zagazig University, Internal Medicine - Gastroenterology Unit, Zagazig, Egypt

AIMS: Gastric varices (GV) occur with an incidence of 20% in patients with portal hypertension. The aim of this study is to evaluate of the efficacy of endoscopic band ligation (BL) as an option in the management of non-bleeding gastric varices in cirrhotic patients. METHODS: 20 patients with moderate, non-bleeding gastric varices with mucosal risky signs of bleeding were subjected to endoscopic BL; they had risk factors of bleeding as INR ≥2, platelet count ≤80,000/μl, serum total bilirubin ≥2 mg/dL, serum creatinine ≥1.5 mg/dL. A matched control group included 20 cirrhotic patients with gastric varices were subjected to endoscopic sclerotherapy using amacrylate for comparison.

RESULTS: Endoscopic BL was performed for 17 patients who had IGV1 (85%) and 3 patients who had GOV1 (15%). mean BL sessions were 1.9 0.6 times, 2 patients had post-BL ulceration (10%), bleeding occurred in 3 patients (15%) and epigastric pain was reported in 3 patients (15%). The control group had 15 patients with IGV1 (75%) and 5 patients with GOV1 (25%). Mean

amacryl sessions were 1.5 0.5 times. Post-sclerotherapy ulceration occurred in 9 patients (45%) (4 in GOV, 5 in IGV), bleeding occurred in 9 patients (45%), 16 patients had epigastric pain (80%). Patients treated with amacryl reported 10% mortality while there was no mortality reported among patients treated with BL (P = 0.2).

CONCLUSIONS: AR-SA Band ligation has better results with a lesser incidence of complications in comparison to amacryl injection for treatment of medium sized risky gastric varices. Conflict of Interest: None declared.

P469: ENDOSCOPIC SUBMUCOSAL DISSECTION TRAINING USING A NEW NEEDLE-TYPE ENDOSURGICAL KNIFE, SPLASH M-KINFE (DND2718B): A FIRST CLINICAL FEASIBILITY STUDY Mitsuhiro Fujishiro1,2, Yoshiki Sakaguchi2, Yosuke Tsuji2, Yosuke Kataoka2, Itaru Saito2, Satoki Shichijo2, Chihiro Minatsuki2, Itsuko Asada-Hirayama2, Daisuke Yamaguchi1, Keiko Niimi2,3, Satoshi Ono2, Shinya Kodashima2, Nobutake Yamamichi2, Kazuhiko Koike2 1

University of Tokyo, Endoscopy and Endoscopic Surgery, University of Tokyo, Gastroenterology, and 3University of Tokyo, Epidemiology and Preventive Medicine, Tokyo, Japan

2

AIMS: The aim of this study is to evaluate the feasibility of ESD training using a splash M-knife (DN-D2718B), because the efficacy and safety of these devices for inexperienced endoscopists is unclear. METHODS: This is a single-center prospective pilot clinical feasibility study. Patients diagnosed with superficial gastrointestinal neoplasms were enrolled. A pre-specified group of ESD trainees, each with experience of less than 30 cases of ESD in their selected fields, performed ESD under expert supervision, using the splash M-knife. The most unique characteristic of this device is the metal disk at the tip of the device. This disk, which is 0.8 mm in diameter, enables effective incision of the mucous layer and muscularis mucosae, and during dissection stabilizes the device. In addition, when the tip is retracted, the electrical current flowing through the knife spreads to the surrounding metal sheath, enabling the entire metal surface of the device, which is 1.8 mm in diameter, to act as a coagulation device. Water irrigation function from the tip is also availabe. En bloc resection rates, R0 resection rates, procedure times, and incidence of intra-operational/post-operational adverse events were assessed.

RESULTS: Between June 2015 and January 2016, 13 cases of esophageal, 27 cases of gastric, and 14 cases of colorectal ESD were performed per-protocol with mean procedure times of 80.9, 117.0, and 76.0 minutes, respectively. Mean resection speeds were 10.2, 12.0, 15.5 mm2/min, respectively. All the lesions were resected in an en bloc fashion, but R0 resection rates were 69.2%(9/13), 100%(27/27), 78.6%(11/14), respectively. There were no intra-operational complications. Incidence of




post-operational adverse events were 23.1%(3/13), 7.4%(2/27), 0% (0/14), resepectively. All post-operational adverse events after esophageal ESD were stricture, and after gastric ESD were delayed hemorrhage.

CONCLUSIONS: ESD training with this novel knife for gastrointestinal lesions is safe and feasible. Conflict of Interest: Mitsuhiro Fujishiro declares that he received lecture honorarium from Takeda Parametrical, Esai Co., Zeria Parametrical, and Nihon Parametrical, and a collaborative fund from HOYA-Pentax company as a chief investigator of The University of Tokyo.

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P471: PERCUTANEOUS ENDOSCOPIC NECROSECTOMY UNDER CONSCIOUS SEDATION IS AN EFFECTIVE TREATMENT FOR PATIENTS WITH INFECTED PANCREATIC NECROSIS AND WALLED OFF NECROSIS Saransh Jain1, Rajesh Padhan1, Sawan Bopanna1, Sushil Kumar Jain1, Rajan Dhingra1, Nihar Ranjan Dash2, Peush Sahni2, Kumble Seetharama Madhusudan3, Shivanand Ramachandra Gamanagatti3, Pramod Kumar Garg1 1

All India Institute of Medical Sciences, Gastroenterology, All India Institute of Medical Sciences, G I Surgery, and 3All India Institute of Medical Sciences, Radiology, New Delhi, India

2

P470: AN ENDOSCOPY NEW ERA: ROBOTIC ASSISTANCE GASTROSCOPY

AIMS: Acute pancreatitis (AP) may be complicated by infected pancreatic necrosis (IPN) which requires drainage and often necrosectomy, preferably by a minimally invasive technique. Our aim was to assess effectiveness of percutaneous endoscopic necrosectomy (PEN) in patients with IPN.

Xiuli Zhang1, Yanmin Li2, Lihua Peng1, Siwen Hao2, Jing Yang1, Chongyang Wang2, Shufang Wang1, Fei Pan2, Yuanyuan Zhou2, Zi Kai Wang1, Zongwei Li1, Xiangdong Wang1, Hongyi Li2, Hao Liu2, Yunsheng Yang1 1

Chinese PLA General Hospital, Digestive Disease Center, Beijing, 2Shenyang Institute of Automation, Chinese Academy of Sciences, State Key Laborabory of Robotics, Shenyang, China

METHODS: Consecutive patients with AP hospitalized in our

AIMS: To develop a robotic assistance system for endoscopy. METHODS: A prototype of robot-assisted master-slave system for gastroscopy is designed and developed. We conducted animal experiments with this new ‘Robot’ and tested its feasibility, safety and function for gastroscopy.

RESULTS: This prototype of new “Robot” consists of two parts, gastroscope delivery arm and operation arm. The delivery arm is capable to adjust the pose of gastroscope for subject’s mouth and implement the movement of gastroscope. The operation arm grasps the control section of gastroscope to steer gastroscope rotation, distal bending, insufflation, rinsing, suction and so on. The gastroscope is operated remotely by a joystick. 30 procedures with pigs were performed in two experimental tests. All parts of esophagus and stomach were clearly and skillfully observed including cardia, fundus, body, gastric angle, pylorus and so on. The average procedure time recorded was 8.52 4.17 min by seven GI consultants.

CONCLUSIONS: The first robotic assistance system for gastroscopy has been successfully developed and tested in animal experiments. Robotic technology indicates a new era for endoscopy. Conflict of Interest: None declared.

tertiary care academic center were included prospectively. Patients with IPN were treated with a step-up approach starting with antibiotics and percutaneous drainage, and if required necrosectomy. Single- or multi-port PEN was done using a flexible endoscope through the percutaneous tract in an endoscopy suite under conscious sedation. PEN procedure comprised of lavage and necrosectomy. Control of sepsis and resolution of collection (s) was the main outcome measure.

RESULTS: During the period from August 2013 to July 2016, 415 patients (mean age 40 14.8 years; 269 males) with AP were studied. Of them, 272 patients had necrotizing pancreatitis and 174 developed IPN or infected walled-off necrosis. Of the 174 patients with IPN, 26 were treated conservatively, 54 underwent percutaneous drainage, 40 required surgery and 53 underwent PEN. Of the 53 patients in the PEN group, 42 (79.2%) were treated successfully - 34 after PEN alone and 8 after additional surgery. Eleven of 53 patients died - 7 after PEN and 4 after surgery. All the 11 patients died due to organ failure which was the only independent predictor of unsuccessful PEN. [Details of PEN and outcome] CONCLUSIONS: PEN using a flexible endoscope done under sedation is an effective minimally invasive technique for patients with IPN with advantages of achieving necrosectomy in areas inaccessible to direct endoscopic necrosectomy, avoiding general anesthesia and bedside procedure in sick patients. Conflict of Interest: None declared.

Number of patients

Mean age (years)

Median interval from onset (days)

Median number of sessions

Need for surgery

Successful Outcome

Mortality

53

39.2 + 13.1

47 (26–196)

4

12 (24%)

42 (79.2%)

11 (20.8%)


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P472V: UNUSUAL VISUALIZATION OF MESENTERIC VESSELS DURING ENDOSCOPIC WALLED OFF NECROSIS DEBRIDEMENT THROUGH PERCUTANEOUS PLACED SELF-EXPANDABLE METAL STENT ~ eres, Hugo Richter, Claudio Navarrete Carlos Harz, Amy Pin Clinica Santa Maria, Endoscopic Surgery, Santiago, Chile

AIMS: To show our experience with endoscopic necrosectomy through a percutaneous placed fully covered self-expandable metal stent (SEMS) in a patient with extended walled off necrosis (WON), surrounding the main abdominal vessels and their exposition after endoscopic debridement. METHODS: The patient signed informed consent and was initially treated by interventional radiology with percutaneous external drainage of the extended infected collections. Since drainage was insufficient with ongoing retroperitoneal sepsis. A fully covered SEMS was deployed for direct endoscopic necrosectomy. We used conscious sedation and CO2 and water insufflation.

RESULTS: The patient underwent six necrosectomy sessions, until total necrotic debridement. There was no significant bleeding or other major complications. Control CT after 3 months showed total resolution with no vascular changes. CONCLUSIONS: Endoscopic necrosectomy through covered SEMS seems to be a safe minimally invasive procedure for dealing with extended WON after severe acute pancreatitis and allows to visualize important surrounding structures, avoiding iatrogenic damage. In this case vital vascular structures. Conflict of Interest: None declared.

P473: CUSTOMIZED BARIATRIC STENT FOR SLEEVE GASTRECTOMY LEAK: RESULTS AND COMPLICATIONS Lyz Bezerra Silva1, Josemberg Campos1, Eduardo Godoy1, Victor Costa1, Maıra Gomes de Souza1, Alvaro Bandeira ~o Neto2 Ferraz1, Manoel Galva Federal University of Pernambuco, Recife, and 2Hospital ~ o Paulo, Brazil Nove de Julho, Sa 1

AIMS: Traditional stents available in the market do not adapt well to SG anatomy, leading to possible complications, such as migration. This study evaluates post-SG endoscopic leak treatment, through placement of a long customized bariatric stent. METHODS: This is a retrospective case series of patients who were submitted to endoscopic treatment through placement of a customized fully covered self-expandable metallic stent (180x25x30 mm or 200x25x30 mm) (Expand Stent®, Plastimed S.R.L., Argentina), specially designed for the SG anatomy. This study took place at Federal University of Pernambuco and Nove de Julho Hospital - Brazil, with local Ethics Committee approval.

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 RESULTS: Eighteen patients were included, mostly female (61.1%), with a mean age of 40.3 years. Leak diagnosis ranged from 4th to 18th POD, all located on His angle. Eleven patients were submitted to previous surgical drainage, and three to CT guided percutaneous drainage. Mean stent placement time was 21.7 days (range 12–40). Stent length was 20 cm in 66.7% and 18 cm in 33.3%, mostly being placed in a trans-pyloric position (72.2%). Endoscopic septotomy was done in two cases only, without further endoscopic measures for other cases. All patients referred severe stent related symptoms, such as nausea, vomiting and retrosternal pain, controlled with oral medications. Stents were removed after a mean of 3.9 weeks (range 3–6), with fistula healing in all cases. Distal migration occurred in 16.7%, treated by endoscopic repositioning. Selflimited hematemesis happened in one case. Pre-pyloric stent position (P = 0.012), 18 cm stent (P = 0.025) and stay longer than 4.5 weeks (P = 0.047) were statistically related to migration. CONCLUSIONS: SG customized stents are a safe and effective option for leak treatment. Most patients will experience gastrointestinal symptoms, which tend to improve. Migration rate in this series was 16.7%, related to shorter stents, placed in a pre-pyloric position and with delayed removal. Conflict of Interest: None declared.

P474: ENDOSCOPIC SUBMUCOSAL TUNNEL DISSECTION FOR LESSER CURVATURE SUPERFICIAL NEOPLASMS Dongtao Shi, Rui Li, Weichang Chen, Deqing Zhang The First Affiliated Hospital of Soochow University, Gastroenterology, Suzhou, China

AIMS: To estimate the safety and efficiency of endoscopic submucosal tunnel dissection (ESTD) for lesser curvature superficial neoplasms. METHODS: 47 patients with lesser curvature superficial neoplasms undergoing endoscopic resection were analyzed retrospectively. 26 patients underwent ESTD and 21 received endoscopic submucosal dissection (ESD). Operation time, security, En bloc resection rate and complications were compared between the two groups. The major difference between ESTD and ESD is that, instead of pre-cutting circumferential mucosal, a submucosal tunnel was created by submucosal dissection from the oral incision to the anal incision. Bilateral resection was then performed to remove the lesion completely.

RESULTS: The differences between the two groups in the age of the patients and the diameter of the lesions had no statistically significant (P > 0.05). En bloc resection rate was 100% in the study group and 90.5% in the control group (19/21), and the difference was statistically significant (P < 0.05). The average operation time was 46 minutes (36~59 minutes), the control group was 67 minutes (48~110 minutes), the difference


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 was statistically significant (P < 0.05). The intraoperative bleeding rate of the study group was 57.7% (15/26), the control group was 100%, the difference was statistically significant (P < 0.05). The incidence of perforation was 0% in the study group and 9.5% in the control group (2/21), and the difference was statistically significant (P < 0.05). There was 1 case of delayed bleeding after operation in the two groups, there were no postoperative perforation, and the difference was not statistically significant (P > 0.05). There were no recurrence and metastasis in the two groups after the operation.

CONCLUSIONS: ESTD for lesser curvature superficial neoplasms can obviously shorten the operation time and have a higher security, compared with the traditional ESD operation. Conflict of Interest: None declared.

P475V: ENDOSCOPIC MANAGEMENT SEPTOTOMY AND DILATION WITH ACALASIA BALLON FOR TWISTING AFTER SLEEVE GASTRECTOMY vio Nascimento Godoy , Josemberg Marins Eduardo Sa ~o-Neto2, Lyz Bezerra Campos1, Manoel Dos Passos Galva 1 1 Silva , Fernanda Barbosa Andrade , Helga Cristina Almeida Wahnon Alhinho1, Milton Ignacio Carvalho Tube1, Alvaro Antonio Bandeira Ferraz1, Helaine Cibelle Tolentino Souza1, Cinthia Barbosa Andrade1, Delgis Arias Martınez1 1

Universidade Federal de Pernambuco, Recife, and 2Gastro ~ o Paulo, Brazil Obeso Center, Sa 1


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angularis and the edge where the staples are applied. The same is true for the staple line when it is reinforced by oversewing.

CONCLUSIONS: Stricturotomy is feasible and might be useful in selected cases for twisting after sleeve gastrectomy. Conflict of Interest: None declared.

P476V: LASER ABLATION AS NOVEL MANAGEMENT TECHNIQUE FOR IMPACTED FOREIGN BODY IN ESOPHAGUS Rohit Gupta, Nakul Morakhia Gut Clinic, Allahabad, India

AIMS: To evaluate a new method of laser disintegration of an impacted denture in esophagus. METHODS: A single case study at a tertiary care endoscopy centre. A 70 year old male presented to us with history of grade III dysphagia for the past 4 weeks after accidental ingestion of a 4 teeth denture. There were no clinical signs of perforation as there was no tachycardia and subcutaneous emphysema. No other investigation was done as patient had poor economic background. Upper GI Endoscopy showed a tightly embedded denture in upper esophagus just beyond the cricopharynx which could not be moved up and down. After many attempts at disimpaction, we decided to disintegrate the denture by a holmium laser.

tomy, which is constructed purposely as a narrow tube and consequently, has a risk of stricture and obstruction. Knowledge of their existence and their mechanisms of production is fundamental to preventing them and preserving the excellent record of safety of this technique. The objective of this study is to identify the anatomic changes in the twisting sleeve gastrectomy and describe an efective management endoscopy in this case. We herein present a video demonstrating the diagnostic endoscopy of the twisting sleeve gastrectomy and endoscopy manegement with stricturotomy with argon plasma and dilation with acalasia ballon for the cure of this complication.

RESULTS: The denture was disintegrated by carefully cutting it. The first area of incision was made at the interface of the teeth and the plate. We then worked our way to cut the body of denture transversely and then in between the teeth. The laser setting was fixed at 12 frequency x 1.5 Joule energy. It took 3 sessions of approximately 25–30 minutes each to totally disintegrate the denture. The separated teeth were extracted by a foreign body forceps. Patient experienced significant decrease in pain and dysphagia. Patient was kept nil orally 48 h on IV fluids and antibiotics. Repeat upper GI Endoscopy after 48 h revealed deep ulcers in upper esophagus on endoscopy but were healing (as compared to just after denture removal). Endoscopy after 3 weeks showed a well epithelialized upper esophagus with mild fibrosis at cricopharynx.

METHODS: First, stricturotomy is performed with argon

CONCLUSIONS: Laser ablation of deeply impacted dentures

plasma 40 to 60 watts, the stricture was incised along the longitudinal axis, incorporating the entire length of the stricture, after the dilation with achalasia balloon with Rigiflex balloon 30 mm (Boston Scientific, Natick, MA), which was gradually inflated (maximum 20 psi). Procedure is performed under deep sedation because 30 mm balloon inflation usually causes abdominal pain, which may persist for several minutes after balloon deflation.

in the esophagus can be undertaken safely thereby obviating the need for thoracotomy. Conflict of Interest: None declared.

AIMS: Twisting of the remanent stomach after sleeve gastrec-

RESULTS: Follow the technical aspects carefully in order to prevent this complication is fundamental. Stricture may be avoided by keeping a safe distance between the incisura


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P477V: SEPTOTOMY AND BALLOON DILATION TO TREAT CHRONIC LEAK AFTER SLEEVE GASTRECTOMY: TECHNICAL PRINCIPLES ~o-Neto1, Josemberg Campos2, Manoel Dos Passos Galva vio Coelho Ferreira2, Lyz Bezerra Silva2, Helga Cristina Fla Almeida Wahnon Alhinho2, Delgis Arias Martınez2, Eduardo vio Nascimento Godoy2, Jones Silva Lima2, Cinthia Barbosa Sa Andrade2, Maira Danielle Gomes Souza2, Fernanda Barbosa Andrade2 ~ o Paulo, and 2Universidade Federal Gastro Obeso Center, Sa de Pernambuco, Recife, Brazil

1

AIMS: Chronic leaks after laparoscopic sleeve gastrectomy (LSG) are often difficult to treat by endoscopy metallic stent. Septotomy has been indicated as an effective procedure, but the technical aspects have not been detailed in previous publications. We herein present a video demonstrating the maneuver principles of this technique, showing it as a safe and feasible approach. METHODS: A 32-year-old male, with BMI 43.4 kg/m2, underwent LSG. On the tenth POD, he presented with a leak and initially was managed with the following approach: laparoscopic exploration, drainage, endoclips, and 20-mm balloon dilation. However, the leak remained for a period of 6 months. On the endoscopy, a septum was identified between the leak site and gastric pouch, so it was decided to “reshape” this area by septotomy. In this case, the endoclip previously used was removed from the septum with forceps to avoid heat transmission. Small staples visualized in the fistula orifice were not completely removed due to technical difficulties and friable tissue.

RESULTS: Two sessions were performed in 15 days, resulting in leak closure. The patient was submitted to radiological control 1 week after the second session, which revealed fistula healing, without gastric stenosis. The nasoduodenal feeding tube remained for 7 days, when the patient started oral diet. This patient was followed for 18 months without recurrence. CONCLUSIONS: Septotomy and balloon dilation were initially performed on a difficult-to-treat chronic fistula after gastric bypass and named before as stricturotomy. This procedure allows internal drainage of the fistula and deviates oral intake to the pouch. In addition, achalasia balloon dilation treats strictures and axis deviation of the gastric chamber, promoting reduction of the intragastric pressure. Septotomy and balloon dilation are technically feasible and might be useful in selected cases for closure of chronic leaks after LSG. Conflict of Interest: None declared.

P478V: SEVERE DEHISCENCE OF GASTROJEJUNAL ANASTOMOSIS POST GASTRIC BYPASS: CURE AFTER PARTIALLY COVERED STENT PLACEMENT WITHOUT DISTAL MIGRATION vio Coelho Ferreira1, Lyz Josemberg Marins Campos1, Fla Bezerra Silva1, Helga Cristina Almeida Wahnon Alhinho1, Maira Danielle Gomes Souza1, Helaine Cibelle Tolentino vio Nascimento Godoy1, Joana Cristina Souza1, Eduardo Sa 1 Silva , Fernanda Barbosa Andrade1, Alvaro Antonio Bandeira ~o-Neto2 Ferraz1, Manoel Dos Passos Galva 1

Universidade Federal de Pernambuco, Recife, and 2Gastro ~ o Paulo, Brazil Obeso Center, Sa

AIMS: Anastomosis dehiscence (AD) after gastric bypass is serious complication and generally has been treated by several reoperations. Endoscopic stents can be another tool to get AD closure. This issue has not been clearly described in literature. We report a case of severe AD treated with stent, presenting a multimedia video that facilitates endoscopic finding of limb for adequate stent fixation. METHODS: A 39-years-old man with a body mass index of 40 Kg/m² was diagnosed with gastric fistula seven days after laparoscopic gastric bypass. At first, he was submitted to laparotomy with abdominal toilet, abdominal drain and gastrostomy. Despite sepsis was controlled, drain output maintained same debit. Patient was submitted to apposition of selfexpandable metallic partially covered stent at 22th POD. Endoscopy showed severe AD at gastrojejunostomy, corresponding to almost total disruption, with difficult visualization of limb. After access of alimentary limb and guidance of SavaryGiliard bougie 0.035 (Wilson-Cook, USA) with radioscopy, SEMS apposition was done. Upper edge of stent was placed in the lower third of the esophagus.

RESULTS: Patient progressed uneventfully. After four weeks, stent removal was attempted. However, it was not possible due to endoluminal tissue hyperplasia. Argon plasma was used to promote proliferative mucosa destruction. After 2 weeks, stent removal was feasible. There is no migration. Early AD closure was observed, without recidivism. Patient did not complained about retrosternal/epigastric pain or discomfort, sialorrhoea or heartburn. Follow-up was longer than 8 months. CONCLUSIONS: Partially covered stent is feasible, safe and effective alternative for the treatment of extensive fistula after RYGB, and should be considered even in cases of severe dehiscence. The use of SEMS is associated with lower migration rates. However, it can be technically difficult. Conflict of Interest: None declared.




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P479: LAPAROENDOSCOPIC RENDEZVOUS FOR TREATING CHOLELITHIASIS WITH CONCOMITANT CHOLEDOCHOLITHIASIS UNSUITABLE FOR LCBDE

P480: SINGLE-CHANNEL ENDOSCOPIC CLOSURE FOR COLONIC DEFECT/PERFORATION WITH NOVEL SEPARATING ENDOLOOP SYSTEM

Zhining Fan, Chenguang Dai, Lili Zhao, Xiang Wang, Li Liu, Min Wang

Zhining Fan, Jiankun Wang, Lili Zhao, Li Liu, Xiang Wang


AIMS: Choledocholithiasis is reported to accompany with cholelithiasis in 10–15% patients. The two-stage approach is widely applied: ERCP and laparoscopic cholecystectomy. Recent studies demonstrated single LCBDE might be efficient and cost effective. For some ERCP-failed cases, intraoperative ERCP (IO-ERCP) using the laparoendoscopic rendezvous technique followed by laparoscopic cholecystectomy was effective and safe. It’s still controversial for defining the ideal treatment of CBD stones. Our aim was to evaluate the advantage of IOERCP combined with laparoendoscopic rendezvous in these cases.

METHODS: For the patients suspected cholelithiasis with concomitant choledocholithiasis, MRCP was performed. Patients were cured by cholecystectomy and LCBDE if no contraindications. IO-ERCP and laparoendoscopic rendezvous would be applicable while the CBD diameter was < 1 cm and the stone number was < 3. The cannulation was performed, and the stones was cleared by basket or balloon. ENBD was carried out routinely, and removed due to no infection, no pancreatitis and no discomfort. For all patient, baseline characteristics, operation procedure, complication, hospitalization period and costs compared.

RESULTS: From 2014 to 2015, a total of 10 patients received the management of combining IO-ERCP and LC. Male/Female was 4/6. The mean diameter of CBD was 0.85 cm (0.7–1.0). The average number of stones was 2.1 (1–3). The average operation time was 120.8 min (98–154 min). No PEP or sever complications occurred. Patients were discharged after 4.8-day (3–7) hospitalization and the average costs were 35,000 RMB (33,000–38,000 RMB).

CONCLUSIONS: Combining IO-ERCP and LC for patients with these indications was efficient, safe and cost effective. Cooperating management ensured the successful cannulation, even without radiography. This innovative strategy could reduce the sphincter damnification, avoid post-operative stricture of CBD and prevent the PEP occurrence. Conflict of Interest: None declared.


AIMS: Successful closure of the defect/perforation is critical for endoscopic treatment. Endoscopic purse-string suture (EPSS) with a double-channel colonoscope has been proved to be safe, feasible and effective, where nylon loop need to be cooperative with metal clips through two channels. But singlechannel colonoscopes are more popular, due to their longer length, flexible operation and cheap price. The outside-bundling loop might be an alternative strategy for EPSS, but not flexible for ascending colon. Novel separating endoloop is innovatively applied here. METHODS: As an independent piece, the nylon loop is delivered firstly and clip-fixed as usual, then tightened up by the hook, which were operated through the same singlechannel. All procedure was similar and flexible as doublechannel endoscope. A 70-year-old man was admitted with a 9month history of increasing defecation. Endoscopic examination and biopsy-histopathology revealed tubulovillous adenoma with moderate atypical hyperplasia in the ileocecal junction. Endoscopic submucosal dissection (ESD) was performed for 100% en bloc resection. The large defect was completely closed as described when using a single-channel colonoscope (CF Q260; Olympus, Tokyo, Japan).

RESULTS: The patient was discharged 5 days after operation without any adverse events. CONCLUSIONS: Assisted by separating endoloop system, EPSS with a single-channel colonoscope is also feasible and safe for endoscopic closure. Conflict of Interest: None declared.

ESOPHAGUS: ENDOSCOPY: ACHALASIA/ POEM/SUBMUCOSA TUMOR RESECTION P481: ADVERSE EVENTS OF PERORAL ENDOSCOPIC MYOTOMY AND THEIR CORRECTION METHODS Shokhrat Mamedov, M. P. Korolev, L. E. Fedotov, A. L. Ogloblin State Budget Educational Institution of Higher Professional Education Saint Petersburg State Pediatric Medical University of the Ministry of Healthcare of Russia, Department of General Surgery with Endoscopy Course, Saint Petersburg, Russia

AIMS: New cutting edge treatment method is Peroral Endoscopic Myotomy. Clinical studies have proven high efficiency of the method and low probability of severe complications.


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Despite of the fact, that the method of esophageal achalasia treatment is highly efficient and minimally invasive, just like all endoscopic manipulations, POEM can also have adverse events. To show most frequent adverse events of POEM and methods of their correction.

METHODS: 39 patients have undergone POEM at the Department of General Surgery with Endoscopy Course of Saint Petersburg State Budget Healthcare Institution “Mariinskaya Hospital”. Among them 7 patients had hypercapnia, 5 patients had tense carboxyperitoneum, 3 patients had a hemorrhage at myotomy, 2 patients had a perforation of mucosa in the area of esophagogastric junction and one patient had problems with clipping of an entry to the submucosal layer because of intense edema because of long-term inflammation process.

RESULTS: Hypercapnia was eliminated by additional anesthesiological measures in the form of hyperventilation, increase in minute ventilation, increase in oxygen percentage in the inspired gas mixture and cutting-off the carbon dioxide. Carboxyperitoneum was eliminated by the way of abdominal paracentesis using Veress needle during the surgery. Hemostasis in case of hemorrhage from divided circular muscles and damaged perforating arteries was made by Coagrasper FD410LR disposable electrosurgical hemostatic forceps. Perforation of mucosa was closed using “Olympus” HX-610-135L endoscopic clips. Suturing of an entry to the submucosal layer in a patient was made using Boston Scientific clips with multiple re-opening opportunity. So, all the adverse events of Peroral Endoscopic Myotomy that we had, were corrected in time, at the surgery and without any extensive surgical interventions. CONCLUSIONS: It is evident that the method of Peroral Endoscopic Myotomy is a new pathogenetically-based, highly effective and - in case of timely eliminations of adverse events the most safe method for patients with esophageal achalasia. Conflict of Interest: None declared.

P482: EARLY CLINICAL EXPERIENCE OF POEM IN KAZAKHSTAN Yerlan Abdirashev National Scientific Center of Surgery named after A.N. Syzganov, Endoscopy Department, Almaty, Kazakhstan

AIMS: We present the early clinical experience of POEM for treatment of achalasia and study of effectiveness of conducted surgery.

METHODS: During the period from January to August 2016, we have done 5 POEM with achalasia II, III and IV grade. Patients were divided into the following groups: by sex (3 men/2 women), by age (23–33, 35–45) and by the degree of achalasia (2 patients II, 2 patients - III, 1 patient - IV). Preoperative evaluation included barium swallow and EGD. Esophageal manometry was not carried out due to absence of necessary equipment. According to Eckhardt scale the main score was 7.9 2.1. Patients had endoscopic treatment by balloon dilatation.

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 RESULTS: Surgery of 3 patients was done without any distinctive features. One patient had the mucosal perforation during myotomy which was clipped hermitically and subcutaneous emphysema was occurred. Second patient, we had the problem with closing of the entrance to the tunnel. Due to pronounced inflammatory of mucous the clipping was failed. In this case after surgery, we placed catheter to esophagus with active aspiration. Also the patient took parenteral nutrition and antibiotic therapy. The average duration of all surgeries was 180 40 minutes. On the 5-th day after surgery all patients swollewed barrium contrast which did not show delay in the cardia. 4 patients was discharged on the 7-th and 1 patient on the 10-th day. On month later after POEM patients had no complains regarding their achalasia. The Eckhardt score was 1.4 2.2. CONCLUSIONS: POEM proved it’s effectiveness in all types of achalasia. The main advantage was it´s high efficiency along with its minimal invasiveness and safety, in comparison with conservative and surgical methods of treatment; the high level of safety for the patient in terms of the risk of infection after surgery, hemodynamic instability, respiratory and metabolic disorders. Conflict of Interest: None declared.

P483: PALLIATIVE MANAGEMENT WITH ESOPHAGEAL STENT IN TUMOR ESOPHAGUS (SECONDARY ACHALASIA) A. M. Luthfi Parewangi Hasanuddin University, Internal Medicine, Makassar, Indonesia

AIMS: Secondary achalasia, also known as pseudoachalasia, is most commonly caused by malignant tumors of gastroesophageal junction (GEJ). The mechanism of pseudoachalasia is a mechanical obstruction at the gastroesophageal junction; treatment, therefore, is aimed at removing the obstruction by surgery, chemotherapy, or radiotherapy. Palliative options have been advocated in the form of the use of metallic stent, especially in patients that are not suitable for surgery. METHODS: We reported a male patient aged 58 years old with chief complain difficulty of swallowing and loss of body weight. From barium swallow illustrating achalasia esophagus. From esophagogastroduodenoscopy result as tumor esophageal (secondary achalasia). Pneumatic Dillation is the most effective non surgical option for patients with achalasia. The patient follow up from November 2015 until August 2016, in Wahidin Sudirohusodo Hospital, Hasanuddin University, Makassar, South Sulawesi, Indonesia.

RESULTS: The first esophagus stenting was performed on March 23th, 2016 under fluoroscopic guidance (by using SEMS stent type). The second esophagus stenting was performed on August 5th, 2016 under fluoroscopic guidance. Endoscopic examination was performed after esophagus stenting to




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evaluate stent position, possibility of bleeding or perforation post intervention.

P485: PREDICTIVE FACTORS OF OUTCOME AFTER ENDOSCOPIC BALLOON DILATATION IN ACHALASIA

CONCLUSIONS: Recurrent dysphagia may also be caused by

riam Sabbah1,2, Dalila Gargouri1,2, He la Elloumi1,2, Norsaf Me Bibani1,2, Dorra Trad1,2, Asma Ouakaa1,2, Jamel Kharrat1,2

tumor overgrowth or ingrowth, epithelial hyperplasia, or adherent debris or blood clot. Therapeutic options for palliating the patient’s dysphagia include balloon dilatation, laser therapy, stent revision, and endoscopic removal of any debris or blood clots. It has been reported a male patient aged 58 years old diagnosed as tumor esophageal (secondary achalasia). Management performed are invasive technique with pneumatic dilation and continued with esophageal stenting. Conflict of Interest: None declared.

P484V: TWO CASES OF SUBMUCOSAL TUNNELING ENDOSCOPIC RESECTION (STER) Jan Martinek, Julius Spicak, Tomas Hucl, Petr Stirand IKEM, Hepato-Gastroenterology, Prague, Czech Republic

AIMS: The aim of this presentation is to present two case reports of “challenging” STER in the esophagus. METHODS: CASE 1: The female patient was reffered with a submucosal esophageal lesion originating from submucosa or m. mucosae according to EUS. Thus, ESD was considered but finally we decided to perform STER. CASE 2: The male patient was reffered with a submucosal lesion which was located in the proximity of aorta. The distance between aorta and the lesion was about 1 mm. STER was performed by using a standard TT knife. The incision was made 3 cm above the tumor and then the submucosal tunnel was created reaching the distal margin of a lesion. By using a gentle dissection, both lesions were completely removed and the incision was closed by clips.

RESULTS: CASE 1: The longitudinal lesion came out to originate from m. propria and not from submucosa. Thus, STER was the only safe approach for its removal. STER was performed without complications and the diagnosis of leiomyoma was established after a final histopathology assessment. CASE 2: STER was carried out without complications and the lesion (GIST) was completely removed. A clear visibility with a good differentiation of surrounding structures (adventicia, aorta) assured the safety of the procedure. CONCLUSIONS: 1. EUS may not be accurate enough in assessing the origin of longitudinal submucosal lesions. STER (in contrast to ESD) is a safe approach for removal of any submucosal lesions. 2. STER is a safe method for removal of a lesion even in a close proximity of aorta (or other mediastinal structures). Conflict of Interest: None declared.

1 Habib Thameur Hospital, Gastroenterology, 2University of Tunis El Manar, Faculty of Medicine, Tunis, Tunisia

AIMS: Endoscopic balloon dilation (EBD) remains an essential option for treatment of achalasia. Success rate is variable depending on the study. The aim of our study was to identify predictive factors of outcome after endoscopic dilatation for primitive achalasia. METHODS: Retrospective study involving patients with achalasia treated by endoscopic balloon dilatation from January 2002 to January 2016 were included. A follow up period of at least 6 months after EBD was required. Balloon dilatation was performed with Rigiflex 30 or 35 mm balloon. Criteria for failure of EBD were defined by need for recourse to a second session of dilatation or Heller cardiomyotomy.

RESULTS: During the studied period, 120 pneumatic dilations were performed. 100 patients whose follow-up was available for at least 6 months were included. Sex ratio was 1.12 [H / F = 53/47] and average age was 42 17 years [7–88]. A recurrence of symptoms was observed in 36% of cases after the first session of endoscopic dilatation justifying a second endoscopic dilatation (in 36 cases) or surgical treatment (Heller’s cardiomyotomy) (in 6 cases). The recurrence of symptoms occurred within 5.1 3 months [1–12 months]. Predictors of failure of PD were age < 30 years (P = 0.01), male gender (P = 0.003), vigorous achalasia (P < 0.0001) and an initial PSIO < 30 mm Hg (P = 0.01). In multivariate analysis male gender (P < 0.001) and vigorous achalasia (P < 0.001) were independent predictors of failure of EBD. CONCLUSIONS: Independent predictive factors of poor response to endoscopic dilatation in our cohort were clinical (male gender) and manometric (vigorous achalasia). This could suggest to use another technique such as per oral endoscopic myotomy if these factors are present. Conflict of Interest: None declared.

P486: ARMS AS TREATMENT OPTION FOR A PATIENT WITH REFRACTORY REFLUX ESOPHAGITIS AFTER POEMΔ Yuichiro Ikebuchi, Joshua Tuason, Mayo Tanabe, Tetsuya Tatsuta, Kazuya Sumi, Yoshitaka Hata, Shota Maruyama, Haruo Ikeda, Manabu Onimaru, Hiroaki Ito, Haruhiro Inoue Showa University Koto-Toyosu Hospital, Digestive Diseases Center, Tokyo, Japan

AIMS: Per-oral endoscopic myotomy (POEM) for treatment of esophageal achalasia was developed in 2008. More than 1200 cases of POEM have been performed for achalasia-related


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diseases. Success rate of the procedure is more than 95% (Eckardt score improvement 3 points and more). No serious (Clavian-Dindo classification IIIb and more) complications have been experienced.

Mean C (Gr. I data) = 0.63 (0.11). Group II (n = 47, 3 - sigmoid) - mean Y, Z, X1 and X2 = 40.55, 4.90, 43.64 (36.69–51.10), 43.69 cm (38–51) respectively. X1/X2 correlation coefficient = 0.98, P < 0.01.

METHODS: A novel endoscopic treatment for gastroe-

CONCLUSIONS: Disparity in distance to GEJ through lumen

sophageal reflux disease (GERD) has been developed. Antireflux mucosectomy (ARMS) is a nearly circumferential mucosal reduction of the gastric cardia mucosa. ARMS has been performed in 61 consecutive cases for refractory GERD. No major complications have been encountered and the clinical results have been satisfactory.

and tunnel is proportional to esophageal diameter. Equation X = Y + CZ can be used to accurately predict GEJ distance during tunneling. Further studies are warranted. Conflict of Interest: None declared.

RESULTS: A case of a 47 years old man, diagnosed with nonsigmoid type I achalasia according to the Chicago classification underwent POEM in June of 2015. After 2 months, the patients had symptoms of GERD with esophagitis (LA classification grade C). Treatment was started with proton-pump inhibitors (PPI) but was ineffective. Treatment with a different kind of PPI was started, but no improvement was noted. Due to the refractory nature of the GERD symptoms, ARMS was performed in August of 2016. After ARMS, he was symptom-free.

P488: EFFICACY OF A WATER-JET-ASSISTED TRIANGLE-TIP KNIFE (TTJ) FOR PER-ORAL ENDOSCOPIC MYOTOMY (POEM) FOR ESOPHAGEAL ACHALASIAΔ

CONCLUSIONS: This case suggests that ARMS is a therapeu-

Showa University Koto-Toyosu Hospital, Tokyo, Japan

tic option for refractory GERD after POEM. Conflict of Interest: None declared.

P487: A SIMPLE MATHEMATICAL EQUATION FOR RELIABLE PREDICTION OF THE GASTROESOPHAGEAL JUNCTION (GEJ) THROUGH THE SUB MUCOSAL TUNNEL DURING PER ORAL ENDOSCOPIC MYOTOMY (POEM) Amol Bapaye1, Jay Bapaye2, Nachiket Dubale1, Rajendra Pujari1, Mahesh Mahadik1, Suhas Date1 1

Deenanath Mangeshkar Hospital, Shivanand Desai Center For Digestive Disorders, 2Smt. Kashibai Navale Medical College, Pune, India

Yohei Nishikawa, Sachiko Ishida, Suguru Ogihara, Joshua Tuason, Mayo Tanabe, Tetsuya Tatsuta, Yoshitaka Hata, Shota Maruyama, Yuichiro Ikebuchi, Haruo Ikeda, Manabu Onimaru, Hiroaki Ito, Haruhiro Inoue

AIMS: Per-Oral Endoscopic Myotomy (POEM) is one of the alternative treatments for esophageal achalasia and other esophageal motility disorders, and since the first human case performed by Inoue in 2008, we have performed more than 1200 cases in our hospital. POEM starts with a mucosal incision, followed by submucosal tunnel creation crossing the esophagogastric junction (EGJ) and myotomy. POEM has conventionally used the Triangle-tip knife: TT (Olympus, Tokyo, Japan). A new endoscopic device, a waterjet-assisted Triangle-tip knife: TTj (Olympus, Tokyo, Japan) is now available. We use this new device for POEM and compare operation time and usability with using the TT. METHODS: We use the TTj for POEM and compare operation time and usability with using the TT.

(GEJ) through tunnel during POEM is challenging. Errors may prolong procedure time or result in incomplete myotomy. Additional distance through tunnel is directly proportional to esophageal diameter; can be calculated by equation X = Y + CZ (X, Y, Z and C = GEJ distance through tunnel, through lumen, max. esophageal diameter & arithmetic constant respectively). This study evaluates accuracy of this hypothesis.

RESULTS: Compared to the TT, water can be supplied to the front. In the POEM procedure, repeated injection of dyed saline during tunneling is performed to enhance the demarcation between the submucosal layer and the muscularis propria. Traditionally, this process requires exchanging the knife for a catheter to spray dyed saline and is time consuming. TTj with water-jet-assistance need not exchange the device. With the TTj the triangle plate is smaller. When myotomy is performed, TTj can be used selectively on the muscle layer.

METHODS: N = 59: Gr. I - 12 retrospective patients; Gr. II - 47

CONCLUSIONS: The TTj need not exchange the device, this

prospective scheduled for POEM. Y recorded during EGD. Z measured on barium swallow. In Gr. I, X measured during POEM and mean C calculated. This mean C used in equation in Gr. II to prospectively calculate predicted X (X1). X1 values blinded from operator. During POEM, operator recorded true X (X2). X1 & X2 compared.

leads to reduced operation time for POEM. Also the smaller triangle plate makes myotomy safer. Conflict of Interest: None declared.

AIMS: Estimation of distance to gastro-esophageal junction

RESULTS: POEM successful in all. Group I (n = 12, 4 - sigmoid) - mean X, Y and Z = 42.58, 39.83 and 4.39 cm respectively.



P489: GASTROESOPHAGEAL REFLUX DISEASE AFTER PER ORAL ENDOSCOPIC MYOTOMY FOR ACHALASIA CARDIA Radhika Chavan, Zaheer Nabi, Mohan Ramchandani, Santosh Darisetty, Rakesh Kalapala, D. Nageshwar Reddy Asian Institute of Gastroenterology, Gastroenterology, Hyderabad, India

AIMS: Peroral endoscopic myotomy (POEM) is an established treatment option for achalasia cardia. There is limited data regarding the prevalence of gastroesophageal reflux after POEM. The aim of present study was to analyze the prevalence of GERD after POEM. METHODS: The data of patients who underwent POEM (from January 2013 to June 2016) for achalasia cardia was prospectively collected and analysed. Gastroesophageal reflux (GER) was assessed using 24 h pH metry and esophagogastroduodenoscopy (EGD).

RESULTS: A total of four hundred eight patients (mean age 40 years, range 4–77 years) underwent POEM during the specified period. POEM could be successfully completed in 396 (97%) patients. Clinical symptoms of GER were detected in 44 out of 261 patients (16.8%). 24 h pH metry was available for 92 patients at 3 months after POEM. De Meester score of >14.7 suggestive of GER was found in 26 patients (28.3%). EGD detected erosive esophagitis in 42 patients (18.5%; 42/227). Most of these patients had mild esophagitis (LA grade A-26, LA grade B -11). Severe esophagitis (LA grade C and D) was found in 5 patients. Proton pump inhibitor was prescribed in all the patients with symptoms and esophagitis (18%).

CONCLUSIONS: The prevalence of GERD by pH study is comparable to that of Heller’s myotomy and pneumatic balloon dilatation. However, fewer patients develop esophagitis and clinical symptoms. Conflict of Interest: None declared.

P490: PER-ORAL ENDOSCOPIC MYOTOMY FOR ACHALASIA CARDIA: OUTCOMES IN OVER 400 CONSECUTIVE PATIENTS Zaheer Nabi, Mohan Ramchandani, Radhika Chavan, Santosh Darisetty, Rakesh Kalapala, D. Nageshwar Reddy Asian Institute of Gastroenterology, Hyderabad, India

AIMS: Peroral endoscopic myotomy (POEM) has emerged as an efficacious treatment modality for the management of achalasia cardia (AC) and non-achalasia spastic esophageal motility disorders. Initial results are encouraging. We analysed the safety and efficacy of POEM in a large cohort of patients with AC. METHODS: The data of patients who underwent POEM (from January 2013 to June 2016) was prospectively collected and analysed. The clinical success was compared with pre and post


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POEM Eckardt scores. Objective parameters including highresolution manometry (HRM) and timed barium swallow (TBS) were analyzed and compared before and after the procedure. Gastroesophageal reflux was analysed using 24 h ph metry and esophagogastroduodenoscopy.

RESULTS: A total of four hundred eight patients (mean age 40 years, range 4–77 years) underwent POEM during the specified period. POEM could be successfully completed in 396 (97%) patients. The clinical success at 1, 2 and 3 years was 94%, 91% and 90% respectively. Mean Eckardt score was 7.07 1.6 prior to POEM and 1.27 1.06 after POEM (P = 0.001) at one year. Significant improvement of esophageal emptying on TBE (>50%) was documented in 93.8% patients who completed 1 year follow up. Pre-procedure and post-procedure mean lower esophageal sphincter pressure was 45 16.5 mmHg and 15.6 6.1 mmHg, respectively (P = 0.001). GERD was documented in 28.3% patients with 24 h pH metry and erosive esophagitis was seen in 18.5% of patients who underwent POEM. CONCLUSIONS: POEM is safe, effective and has a durable response in patients with achalasia cardia. Conflict of Interest: None declared.

P491: PER ORAL ENDOSCOPIC MYOTOMY FOR FAILED HELLERS MYOTOMY IN PATIENTS WITH ACHALASIA CARDIA: OUR EXPERIENCE Radhika Chavan, Mohan Ramchandani, Zaheer Nabi, Santosh Darisetty, Rama Kotla, Rakesh Kalpala, D. Nageshwar Reddy Asian Institute of Gastroenterology, Hyderabad, India

AIMS: To assess the efficacy and safety of per oral endoscopic myotomy (POEM) in previously failed Hellers Myotomy in patients with achalasia cardia. METHODS: All the patient who underwent POEM with history of failure to Hellers Myotomy retrospectively analyzed. Primary outcome for study was symptom improvement with Eckardts score less than 3. Secondary outcome for study was emptying of barium on timed barium swallow and procedure related complications.

RESULTS: Total 408 patients underwent POEM in our centre during Jan 2013 to Jun 2016. Total 26 patients (Male-16, female10) had history of recurrence of symptoms after Hellers Myotomy. Mean age of the patients 44.8 12. Twenty five patients underwent POEM successfully. In view of severe fibrosis POEM could not be completed in 1 patient. Anterior myotomy was done in 5 patients while posterior myotomy was done in 20 patients. Mean myotomy length was 13.3 3.2 cm. Procedure related complication included mucosal injury (n–1), pneumoperitoneum (n–6), retroperitoneum (n–7) and pneumothorax (n–1). Total 22 patients completed 1 year follow up. Mean Eckardt score was 6.5 1.4 prior to POEM and 1.3 0.6 after POEM (P = 0.001) at one year. Significant improvement of esophageal emptying on TBE (>50%) was documented in 90%


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patients who completed 1 year follow up. There was significant decrease in lower esophageal sphincter pressure from preprocedure (44 11.2 mmHg) to post-procedure 14 5.7 mmHg, respectively (P = 0.001).

CONCLUSIONS: Per oral endoscopic myotomy is safe and effective treatment in patients with achalasia cardia with failed Hellers myotomy. Conflict of Interest: None declared.

P492: ACHALASIA EXPERIENCE IN A TERTIARY NORTH WEST OF ENGLAND HOSPITAL Sandev Singh Aintree University Hospital, Liverpool, UK

AIMS: Achalasia is a relatively uncommon motility disorder with risks of oesophageal cancer however the gravity of this risk remains unclear. Gastroenterology societies do recommend against routine endoscopic surveillance for cancers. We aim to share our tertiary hospital experience. METHODS: We conducted a cross-sectional study of patients manometrically defined with achalasia in our institution between December 2007- February 2015. Clinical data for demographics, symptom duration, treatment modalities and cancer development were obtained from electronic patient records. Nine patients referred from other hospitals for oesophageal manometry were excluded from further analysis.

RESULTS: Forty patients had achalasia. Demographic parameters indicated that most were men (n = 21), mean age for men was 50 18 (range: 18–78) and women were 46 17 (range: 20–76). Gender was not associated with typical OGD findings associated with achalasia [M: 12 (63.2%); F: 7 (36.8%), P = 0.52) similarly, barium swallow findings did not differ by gender. The median duration of symptoms prior to diagnosis were 19 and 24 months for men and women, respectively (P = 0.36). Mean LOS pressure was 27.1 mmHg (M: 26.6; F: 27.7). The majority of patients had single treatment modality of which laparoscopic Heller’s cardiomyotomy (n = 17), pneumatic dilatation (n = 16) and Botox injection (n = 5). Two patients had dual treatment modality. Complication rates was low (2.5%). Six patients were symptomatic (dysphagia, vomiting, chest pain), 28 patients asymptomatic and unknown in the rest at follow up post treatment. Fourteen patients (35%) had surveillance OGD at 2 or 3-year intervals of which 10 patients had a Heller’s cardiomyotomy. Two patients (5%) were confirmed to have oesophageal cancer on routine non-surveillance OGDs.

P493: EFFICACY AND SAFETY OF PER-ORAL ENDOSCOPIC MYOTOMY: A SERIES OF 180 PATIENTSΔ Hironari Shiwaku1, Kanefumi Yamashita1, Taisuke Matsuoka1, Hiroki Okada1, Toshihiro Ohmiya1, Hirofumi Yoshimura1, Satoshi Nimura2, Haruhiro Inoue3, Suguru Hasegawa1 1

Fukuoka University Faculty of Medicine, Department of Gastroenterological Surgery, 2Fukuoka University Faculty of Medicine, Department of Pathology, and 3Showa University Koto-Toyosu Hospital, Digestive Disease Center, Tokyo, Japan

AIMS: POEM is a revolutionary therapy for achalasia that was first reported by Inoue and colleagues. Subsequently, many reports have described the safety and efficiency of POEM; however, reports of a large series of patients treated with POEM are rare. The aim of this presentation is to report the outcomes of POEM in a cohort of 180 patients. METHODS: The first 180 patients treated using POEM in a single center were retrospectively identified. Follow-up data, including clinical evaluations, the results of esophagogastroduodenoscopy (EGD), manometry, and pH monitoring, were collected and analyzed.

RESULTS: A total of 180 achalasia patients patients underwent POEM between September 2011 and September 2016 at our institution. The mean patient age (mean standard deviation) was 48.9 18.3 years (range, 9–91). Fifty-seven patients had undergone previous therapy (forty-three balloon dilations, ten Heller-Dor, three POEM and one Botox injection). The mean total length of the myotomy was 14.7 5.3 cm (range, 5– 26 cm), and the mean length of the gastric myotomy was 2.8 1.5 cm (range, 1–5 cm). The mean preoperative and postoperative integrated relaxation pressure (IRP) were 33.0 14.6 and 15.3 6.3 mmHg, respectively; there was a statistically significant decrease in IRP after POEM. Furthermore, the Eckardt score decreased significantly from 5.8 2.3 preoperatively to 1.0 1.0 postoperatively. Adverse events over Grade IIIb by the Clavien-Dindo classification were not encountered. CONCLUSIONS: The outcomes in patients who underwent POEM were excellent. POEM is less invasive and has a higher curative rate than conventional therapeutic methods; therefore, POEM is expected to become the standard treatment worldwide for esophageal achalasia. Conflict of Interest: None declared.

CONCLUSIONS: Management of patients with achalasia in our unit is effective with low complication rates. Larger datasets is crucial to determine whether surveillance for oesophageal cancer in this group of patients is cost-effective with the hope of providing clearer guidance to gastroenterologist managing this condition. Conflict of Interest: None declared.



P494: INTRODUCTION AND ADOPTION OF A NEW ENDOSCOPIC PROCEDURE: PERORAL ENDOSCOPIC MYOTOMY (POEM) Kevin Dasher, Vinay Chandrasekhara, Greg Ginsberg University of Pennsylvania, Philadelphia, USA

AIMS: Adoption of a new endoscopic procedure may require preparation and planning to include training, inventory, credentialing and privileging, and multidisciplinary collaboration. Peroral endoscopic myotomy (POEM) is an endoscopic technique that provides a non-surgical treatment for achalasia. This abstract will outline a single center experience with introduction and adoption of POEM at an academic medical center. This abstract will detail a program for the introduction and adoption of the POEM procedure and its clinical outcomes. METHODS: All achalasia patients consecutively treated with POEM were included in the review. The examined clinical outcomes were Eckhart scores, serious adverse events, and reflux symptoms.

RESULTS: An integrated esophageal motility program, including physiologists and foregut surgeons, provided the platform for POEM adoption. A training and adoption plan was approved by the Institutional Review Board providing oversight of the first 10 cases and a plan for training and adoption was reviewed and approved by the hospital Credentialing Committee. An experienced therapeutic endoscopist conducted video review and direct observation of several POEM procedures, supplemented by training on ex-vivo tissue models. Upon introduction, the first 2 POEM procedures were performed with an experienced proctor on site. A second endoscopist has subsequently trained internally. Since introduction in April 2014, 44 patients underwent 47 POEM procedures (mean age 50.7 years, 61% men). Mean procedure duration was 90.8 min. Mean f/u = 368 days (range 1 to 29 months). Initial clinical response, defined by an Eckhart score of ≤3, was seen in 36/44 patients (82%). Mean Eckhart scores decreased from 8.2 to 1.3 after POEM. 13/44 (30%) of patients required acid suppression therapy in the follow up period. One patient experienced a mild adverse event. CONCLUSIONS: Institutional and individual planning and preparation enable safe, effective, and durable introduction and adoption of POEM. This experience forms a template for new procedure adoption. Conflict of Interest: None declared.

P495: APPLYING QUALITY METRICS TO PERORAL ENDOSCOPIC MYOTOMY OUTCOMES Kevin Dasher, Vinay Chandrasekhara, Greg Ginsberg


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of achalasia. Since its inception in 2008, multiple centers have introduced POEM into their clinical practice. Given that POEM is a novel technique, the American Society for Gastrointestinal Endoscopy published threshold performance measures necessary to validate POEM as a therapeutic option. These guidelines were published as part of the ASGE’s guidelines on the preservation and incorporation of valuable endoscopic innovations (PIVI). The specific stipulations include

(1) 80% OR GREATER EFFICACY 12 MONTHS AFTER THE PROCEDURE AND: (2) a 6% or lower serious adverse event rate within 30 days after the procedure. We compared our single center outcomes with the standards outlined by ASGE. In this abstract, we aim to retrospectively review performance characteristics of POEM procedures at our center, from inception of POEM to present and to compare our outcomes with those threshold outcomes suggested by national guidelines.

METHODS: From April 2014 to present, 44 patients underwent POEM at our center. The medical records of these patients were reviewed to define outcomes, as defined by Eckhardt scores and procedure associated morbidity.

RESULTS: 44 patients underwent 47 POEM procedures (mean age 50.7 years, 61% men). They were followed for an average of one year (range 1 to 29 months). Initial clinical response, defined by an Eckhardt score of ≤3, was seen in 36/44 patients (82%). After a second POEM in 3 patients with persistent symptoms, clinical success was achieved in 39/44 patients (87%). Early safety outcomes included one episode of pneumoperitoneum, managed with intraprocedural angiocatheter decompression, considered a mild adverse event by ASGE criteria. CONCLUSIONS: The results at our center support the integration of POEM into the management of achalasia. Internal review of POEM outcomes is an important mechanism to ensure satisfactory outcomes at all centers. Conflict of Interest: None declared.

P496: THE OUTCOMES AND QUALITY OF LIFE OF CHINESE PATIENTS WITH ACHLASIA AFTER PERORAL ENDOSCOPIC MYOTOMY: A MULTICENTER CLINICAL STUDY Dongtao Shi1, Rui Li1, Weichang Chen1, Ping Yao2, Wenkai Ni3 1 The First Affiliated Hospital of Soochow University, Gastroenterology, Suzhou, 2The First Affiliated Hospital of Xinjiang Medical University, Gastroenterology, Urumchi, and 3 The First Affiliated Hospital of Nantong University, Gastroenterology, Nantong, China

University of Pennsylvania, Philadelphia, USA

AIMS: Peroral endoscopic myotomy (POEM) is an endoscopic technique that provides a non-surgical option for the treatment

AIMS: To assess quality of life (QOL) and psychological state of patients with achalasia after peroral endoscopic myotomy (POEM).


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METHODS: Six hundred and eight-seven achalasia patients underwent POEM from Jan 2011 to December 2015. The data on clinical evaluation and QOL before therapy, at 1 month and 6 months postoperation were collected and analyzed. Meanwhile, Zung´s Self-rating anxiety Scale (SAS) and self-rating depression scale (SDS) were used to assess the anxiety and depression.

RESULTS: All the six hundred and eight-seven patients underwent POEM successfully. By comparing the data of the preoperative with that of 1 month and 6 months after POEM respectively, we found that: mean Eckardt score decreased (8.1 1.3 vs 1.27 0.31, 8.1 1.3 vs 0.61 0.52, all P < 0.05), esophagus diameter reduced (53.82 mm vs 32.1 mm, 53.82 mm vs 28.31 mm, all P < 0.05), and esophageal manometry declined (31.7 mmHg vs 12.3 mmHg, 31.7 mmHg vs 10.1 mmHg, all P < 0.05). No complications and recurrence occurred in all cases. At each time point, postoperative QOL scores were higher than those of preoperative (P < 0.05). The anxiety and depression scores of preoperative patients were higher than normal group (SAS 51.32 7.26 vs 31.72 7.21, SDS 53.17 5.98 vs 29.75 8.01, all P < 0.05), which were closely related to the severity degree of symptom (P < 0.05). A comparison between the postoperative and preoperative groups (SAS 51.32 7.26 vs 37.2 7.18, SDS 53.17 5.98 vs 35.72 7.36, all P < 0.05) demonstrated a significent difference reduced by POEM. CONCLUSIONS: POEM is safe and effective for treating achalasia, it can relieve clinic symptoms as well as improve patients’ QOL, effectively relieving negative emotion. Conflict of Interest: None declared.

P497: DUAL CAUSES OF DYSPHAGIA IN A SINGLE PERSON: ACHALASIA CARDIA AND DYSPHAGIA LUSORIA Partha Pal, Sundeep Lakhtakia, Zaheer Nabi, Mohan Ramachandani, Radhika Chavan, D. Nageshwar Reddy Asian Institute of Gastroenterology, Gastroenterology, Hyderabad, India

AIMS: Achalasia cardia (AC) is characterized by aperistalsis and impaired lower esophageal sphincter (LES) relaxation, whereas dyphagia lusoria occurs due to compression of esophagus by aberrant right subclavian artery causing characteristic pencil-like indentation on esophagus in barium esophagogram. As both diseases are rare, it is very unusual to find them together in the same patient. We describe a case with both vascular and motility components of dysphagia.

METHODS: A 47-year-old male from middle-east presented with complain of dysphagia to solids and liquids, occasional regurgitation without chest pain and weight loss. Esophagogastroduodenoscopy (EGD) showed resistance at LES with dilated esophagus. High resolution manometry (HRM) was consistent

with achalasia cardia. POEM was performed with anterior approach.

RESULTS: On subsequent follow up, he complained of intermittent dysphagia only to solids especially on first swallow. HRM suggested significantly reduced LES pressures arguing against failure of POEM procedure. Barium swallow showed free flow of contrast across gastro-esophageal junction; however a pencil like indentation was visible in upper esophagus. To further evaluate, Contrast tomography (CT) angiography was done which revealed aberrant right subclavian artery compressing the esophagus suggesting dysphagia lusoria. He was managed with dietary modifications and is asymptomatic till last follow up. CONCLUSIONS: Persistent dysphagia after treatment of AC is usually due to inadequate initial therapy or recurrence of disease after initial success. Rarely an alternate cause of dysphagia like dysphagia lusoria coexists and should be sought if objective parameters like HRM suggest success. Dysphagia lusoria rarely causes symptoms, and in many cases can be managed by simple dietary modification obviating the need for surgery. Conflict of Interest: None declared.

P498: LONG-TERM OUTCOME AFTER ENDOSCOPIC PNEUMATIC DILATATION IN ACHALASIA Abhinav Jain1, Megha Meshram1, Akash Shukla2, Vinit Kahalekar1, Shobna Bhatia2 1

Seth GS Medical College and KEM Hospital, 2Seth GS Medical College and KEM Hospital, Gastroenterology, Mumbai, India

AIMS: Endoscopic pneumatic dilatation (PD) is a safe and effective treatment patients with achalasia. There is variable prognosis after PD based on subtypes recognised at manometry. In recent years, POEM is becoming a valuable endoscopic method to manage achalasia. However, PD still remains a good option to treat patients. There are few reports of long-term follow up of achalasia after PD; hence we evaluated the response to PD iafter 4 years of treatment, and correlated it to the manometric subtype. METHODS: Patients diagnosed as achalasia at water-perfusion esophageal manometry between Jan 2006 to Sept 2012, with a follow up for at least 4 years were included. Patients who had undergone dilation or surgery prior to manometry were excluded. Their baseline data and history were recorded. The type of achalasia was decided on basis on Chicago classification v 3.0. All patients underwent endoscopic PD. Dilations performed < 1 month apart were taken as a single dilation. Dilation was done under conscious sedation using 30 mm Rigiflex dilator, at 6 psi for one min. If there was no response in the first 2 weeks, dilation was repeated with 35 mm dilator. Baseline and post-intervention Eckardt score were recorded. Response was defined as Eckardt score of < 3. All subjects gave consent, and the protocol was approved by the Ethics Committee.




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RESULTS: 56 patients (age 40.3 + 15 years; 24 men) patients

CONCLUSIONS: The rate of neoplasia detection on index

were included. The median duration of symptoms prior to diagnosis was 12 months. The results of dilation in the 3 subtypes of achalasia are shown in the Table. Three (type I–2, type II - 1) patients underwent laparoscopic Heller’s myotomy after failure of first dilation. One patient of type I achalasia underwent POEM after failure of dilation.

endoscopy for screening for Barrett’s esophagus is 18% (1 in 5 BE patients may harbor dysplasia on their initial index EGD). Based on these results, careful examination of the esophagus should be performed during index endoscopy when BE is detected. Given that the development of dysplasia/cancer in BE patients undergoing surveillance is low, screening endoscopy might be the most important endoscopy. Conflict of Interest: None declared.

CONCLUSIONS: PD is a good first-line management option with good long-term relief in symptoms. Conflict of Interest: None declared.

ESOPHAGUS: ENDOSCOPY: BARRETT’S ESOPHAGUS, SCREENING, SURVEILLANCE P499: PREVALENCE OF DYSPLASIA AND ESOPHAGEAL ADENOCARCINOMA (EAC) ON INDEX EGD IN BARRETT’S ESOPHAGUS (BE) IN THE UNITED STATES: A SYSTEMATIC REVIEW Sravanthi Parasa1, Asad Pervez2, Kevin Kennedy3, Sreekar Vennelaganti4, Prateek Sharma5 1 Case Western Reserve University, Department of Medicine, Division of Gastroenterology, Cleveland, 2University of Kansas Medical Center, Department of Internal Medicine, Kansas CIty, 3St Luke’s Hospital, Kansas City, 4Kansas City VA Medical Center, Kansas City, and 5Kansas City VA Medical Center, Gastroenterology, Kansas City, USA

AIMS: EGD is performed to screen patients per the established guidelines to evaluate for longer term risks including BE and EAC. The purpose of this systematic review was to obtain summary estimates of the prevalence of dysplasia associated with BE and EAC as determined during index endoscopy. METHODS: An extensive search was performed within PUBMED, EMBASE and the Cochrane Library databases to identify studies in which patients underwent index endoscopy for evaluation of the presence of Barrett’s esophagus in the United States. Two reviewers independently evaluated study eligibility and methodological quality. The pooled dysplasia rates were calculated and were further stratified by the type of dysplasia i.e High Grade dysplasia (HGD), Low Grade Dysplasia (LGD) and EAC. Study heterogeneity and publication bias were also tested.

RESULTS: For the calculation of dysplasia prevalence rates, a total of 6 studies with 3631 patients met the inclusion criteria. The pooled prevalence rate of dysplasia associated with BE was 18% (95 % CI 12, 27 (REM); (six studies- 588/3631 cases) I2 (I squared) =96% and Egger’s test for bias; P = 0.68; for HGD detection was 4% (95% CI 3, 7 (REM); (six studies- 166/3631) I2 = 88.2% and Egger’s test P = 0.44; for LGD Detection was 12% (REM) (95%CI 7, 18; eight studies - 458/4009) (P < 0.0001) I2 = 96% and Egger’s test P = 0.78; and for EAC was 8% (95% CI 6, 9; six studies- 260/3631 cases), P = 0.02, I2 = 61.2% and Egger’s test P = 0.35.

P500: A COHORT STUDY OF ADVANCED IMAGING ENDOSCOPY IN BARRETT’S OESOPHAGUS: CAN DYSPLASIA DETECTION BE IMPROVED IN DAILY CLINICAL PRACTICE? Sabina Beg1, Mark Fullard2, Liz Finnerty2, Paul Richman3, Anthony Leahy2 1 Nottingham University Hospital, Gastroenterology, Nottingham, 2West Hertfordshire NHS Trust, Gastroenterology, Watford, and 3West Hertfordshire NHS Trust, Histopathology, Watford, UK

AIMS: Several advanced imaging techniques have been proposed to improve the visualisation of dysplastia within Barrett’s epithelium, with some evidence for the use of narrow band imaging (NBI) and acetic acid chromendoscopy (AAC). Enhanced characterisation of mucosal morphology using NBI and AAC has been exclusively studied in tertiary hospital settings. We aimed to establish whether NBI and/or AAC increases the detection of dysplasia in routine clinical practice. METHODS: We retrospectively analysed cases of Barrett’s oesophagus examined between April 2007–10 within a community hospital. A change in practice was instituted between April 2011–14, whereby Barrett’s epithelium was inspected with both WLE and NBI in all patients. Where the length of Barrett’s was 3cms or more, 2% AA was applied and loss of acetowhitening was observed after a 2 minute period. We compared the dysplasia detection rate between these cohorts.

RESULTS: In 2007–10, Barrett’s oesophagus was identified during 560 gastroscopies in 392 patients. The mean maximal Barrett’s length was 4.4 cm (range 1–10 cm). During 2011–14, Barrett’s oesophagus was identified during 856 endoscopies in 630 patients. The mean maximal Barrett’s length was 3.8 cm (range 1–16 cm). In 2007–10, the prevalence of dysplasia was 10.8% (n = 43). The incidence of low grade dysplasia was 2.3% and high grade dysplasia/cancer 1.1%. This compared to a dysplasia prevalence of 10.4% (n = 71), with an incidence of low grade dysplasia of 1.1% and high grade dysplasia/cancer of 0.6% between 2011–14. Stastistical analysis demonstrated that there was no significant difference in the prevalence or incidence of dysplasia detected by either approach. CONCLUSIONS: This study demonstrates NBI and AAC in the imaging of Barrett’s oesophagus did not result in an increased detection rate of dysplasia in routine clinical practice. These


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findings concur with the recommendations of existing guidelines, which advocate the continued use of quadrantic biopsies for surveillance. Conflict of Interest: None declared.

P501: A SYSTEMATIC METHODOLOGY IMPACTING BARRETT´S OESOPHAGUS ENDOSCOPY & SURVEILLANCE Ronit Das, Aditya Mandal

P502: BARRETT’S ESOPHAGUS ULTRA-HIGH MAGNIFICATION ENDOSCOPIC DIAGNOSTICS Sergey Pirogov1, Viktor Sokolov1, Andrey Kaprin2, Dmitry Sokolov1, Elena Karpova1, Dmitry Sukhin1, Tatyana Karmakova3, Nadejda Volchenko4, Emma Yagubova4 1

P.A. Herzen Moscow Oncology Research Institute, Endoscopy, 2P.A. Herzen Moscow Oncology Research Institute, 3P.A. Herzen Moscow Oncology Research Institute, Experimental Dept., and 4P.A. Herzen Moscow Oncology Research Institute, Pathology, Moscow, Russia

Lincoln County Hospital, Gastroenterology, Lincoln, UK

AIMS: Following on from an initial audit we report the impact of the institution of a low-cost, dual faceted, evidence based approach to improve Barrett’s Oesophagus (BO) reporting standards. Results from the initial audit of standardized BO reporting in 250 endoscopies (representing forty percent of the annual Barrett’s surveillance at a large NHS Trust) were presented at the 2016 BSG National Conference. Reporting standards were found to be variable & required improvement overall. Adherence to the ‘Prague Classification’ was demonstrated in 56% of reports (141 of 250). What remains poorly established are concrete methodologies to systematically improve Barrett’s reporting and surveillance. This quality improvement exercise forms the first report of such a methodology. METHODS: The first facet of change relates to the endoscopists decision making. The practice of endoscopy falls firmly within ‘Kolb’s Experiential Learning’ model, where experience forms internal conceptualizations, which are further applied in practice. (Kolb 1984) To augment the endoscopists metacognitive process, when internal concepts are developed, we instituted an educational intervention. A produced website (http://barrettsreporting.weebly.com/) delievered a BO evidence update, review of reporting standards, and finally promoted reflection with a self-evaluation. Departmental endoscopist engagement was mandated. The second facet of change was the re-organisation of endoscopy services to provide all BO surveillance in weekly UGI endoscopy lists. This focussed organisation has demonstrably improved LGI pathology recognition and intervention in the national ‘UK Bowel-Scope’ programme. (Gov. 2013)

RESULTS: Data collection & re-audit is ongoing. Final results will be available in December 2016. CONCLUSIONS: There are no published accounts of systematic, evidence-based methodologies in the improvement of Barrett’s Oesophagus reporting. Given that endoscopy quality can be linked to patient outcome, the importance of such processes is high. (Faigel 2006) The given methodology and its evaluation will form the first account of intervention effect on BO endoscopy reporting. Conflict of Interest: None declared.

AIMS: To estimate the value of novel ultra-high magnification endoscopy in Barrett’s Esophagus (BE) diagnostics. METHODS: 344 patients with suspected BE admitted to P.A. Herzen Moscow Cancer Research Institute in 2012–2016. In 24.1% cases long-segment (3 cm and more) metaplastic epithelium was detected, while in 75.9 - short-segment (1–3 cm). We have performed multimodal endoscopic diagnostics, including white-light endoscopy (WLI), narrow-band imaging (NBI), and ultra-high magnification endoscopy: confocal laser endomicroscopy (CLE) (26 examinations) and endocytoscopy (EC) (5 examinations). For CLE we have used probe-based system Cellvizio with GastroFlex UHD probe and l intravenous 5 m Fluorescein sodium administration. For EC Olympus XEC-300 endocytoscope prototype with x570 magnification and 1% methylene blue dye with 4-min. exposition were implemented. Ultra-high magnification endoscopy diagnostics was performed under general anesthesia (Propofolum).

RESULTS: We have analyzed results of our study and found, that Barrett’s esophagus (specialized intestinal metaplasia >1 cm) was confirmed by pathology only in 37.1% suspected with WLI cases of squamous epithelium metaplasia and in 62.9% cases the metaplastic changes were represented by gastric epithelium without intestinalization. Moreover, proven intestinal metaplasia in most (94.2%) cases located only as islands within gastric epithelium in distal esophagus. NBI endoscopy with pit pattern evaluation, according to Sharma P. classification (villous, cerebral, oval and irregular) provides only 79% accuracy in specialized intestinal metaplasia detection. We have evaluated CLE in BE diagnostics with the goblet cells, clearly visible as oval-shaped dark spots, presence criteria and confirmed accuracy - 96.1%. EC in all 5 cases we have also observed intensively dyed with methylene blue goblet cells, intestinaltype epitheliocyte nuclei also can be clearly visible with EC. CONCLUSIONS: Ultra-high magnification endoscopy (CLE an EC) is probably the most accurate diagnostic approach in detection specialized intestinal metaplasia in esophagus. Conflict of Interest: None declared.



P503: CLINICAL PICTURE OF PATIENTS WITH BARRETT’S ESOPHAGUS AND DIFFERENT GRADES OF DYSPLASIA


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ESOPHAGUS: ENDOSCOPY: BARRETT’S ESOPHAGUS, THERAPY

zquez, Ernesto Vivianne Anido Escobar, Mirtha Infante Vela Corujo Arias, Osvaldo Seijas Cabrera

P504: LONG TERM OUTCOMES OF MULTIBAND MUCOSECTOMY FOR DYSPLASTIC BARRETT’S ESOPHAGUS

National Center for Minimally Invasive Surgery, La Habana, Cuba

Gene K. Ma1, Jonathan Lewis2, Gregory G. Ginsberg1 1

AIMS: Barrett’s esophagus (BE) is the most relevant premalignant condition for the development of carcinoma of the esophagus, and the presence of dysplasia represents a progression marker. Our objectives are to identify the different clinical manifestations in a group of patients with BE and different grades of dysplasia. METHODS: An observational, descriptive and transversal study was carried out which included 86 patients with a diagnosis of BE, seen at the Endoscopy Department from the National Center for Minimally Invasive Surgery between January 2012 and January 2014. Clinical-epidemiological variables were compared according to the presence or not of dysplasia and its grade.

RESULTS: 52 male patients were included (60.5% CI 95%: 49.5– 71.3) and 34 females (39.5% CI 95%: 28.6–50.4), average age 49.07 15.5 years. Patients with white skin prevailed, 77 (89.5% CI 95%: 82.4–96.5). 49 cases had no dysplasia (57%, CI 95%: 45.93–68.02); high-grade dysplasia was found in five cases (5.8% CI 95%: 1.91–13.04) and low-grade dysplasia in 32 (37.2% CI 95%: 26.41–48.006). Dysplasia was found in younger individuals, with 45.5 16.5 years (CI 95%: 39.5–51.4) and 41.6 (20.5) years (CI 95%:16.1–67) as average age for those with low and high-grade dysplasia, respectively. The progression of symptoms in patients with low-grade dysplasia was longer (8.7 7.9 years). The body mass index (BMI) was higher in the group without dysplasia (26.4 4.3).

CONCLUSIONS: There are differences regarding age and progression of typical symptoms in patients with dysplasia. Nevertheless, the rest of the assessed conditions were not always present; so, it could be not demonstrated their relationship with the disease in this group of patients. KEYWORDS: Barrett’s esophagus, dysplasia, clinical picture, endoscopy. Conflict of Interest: None declared.

University of Pennsylvania Perelman School of Medicine, Division of Gastroenterology, and 2University of Pennsylvania Perelman School of Medicine, Philadelphia, USA

AIMS: Multiband mucosectomy (MBM) is utilized for targeted resection in dysplastic Barrett’s esophagus (DBE). The aim of this study is to evaluate the safety and efficacy of MBM in the treatment of DBE. METHODS: A retrospective review was performed of patients who underwent MBM of DBE from 2006–2016. Patients were excluded with less than 12 months of endoscopic surveillance post-MBM.

RESULTS: 170 patients underwent 229 MBM procedures for DBE. 111 had at least 12 months of endoscopic surveillance and underwent 174 MBM procedures for a total of 531 applications. 19 (17.1%) were female, and the mean age was 66.1 years. The mean number of resections per case was 3.01 (S.D. 1.52; range 1–9). The percent of luminal circumference ranged from 20– 70%. Among cases wherein multiple resections were performed, 94.6% were confluent. Pathology revealed 6 (5.4%) with no dysplasia, 7 (6.3%) with low grade dysplasia (LGD), 50 (45.0%) with high grade dysplasia (HGD), and 48 (43.2%) with adenocarcinoma (44 T1a, 4 T1b). Adjunctive ablation was utilized in 73 (65.8%) cases. The average length of follow-up was 46.4 months. 11 (9.9%) patients had recurrence of HGD or adenocarcinoma after eradication; the average time at recurrence was 26 months. 10/11 (90.9%) were treated with endoscopic therapy. Adverse events included 4 (2.2%) cases of selflimited chest pain, 3 (1.7%) cases of acute bleeding, 1 (0.6%) suspected perforation (treated with through the scope clips), and 14 (8.0%) strictures requiring dilation. Pathology, n (%) No dysplasia LGD HGD Adenocarcinoma MBM as monotherapy, n (%) Adjunctive ablation, n (%) For LGD For HGD For adenocarcinoma Adverse events, n (%) Chest pain Bleeding

6 (5.4%) 7 (6.3%) 50 (45.0%) 48 (43.2%) 38 (34.2%) 73 (65.8%) 5 (4.5%) 17 (15.3%) 5 (4.5%) 4 (2.2%) 3 (1.7%)


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CONCLUSIONS: Accuracy for MM/SM1 did not differ between

(Continued) Pathology, n (%) Perforation Stricture

1 (0.6%) 14 (8.0%)

[Characteristics of MBM procedures]

CONCLUSIONS: MBM for DBE is safe and effective with a low rate of recurrence. These data support the routine use of MBM as first-line targeted therapy for DBE. Conflict of Interest: None declared.

ME-NBI and EUS. EUS should be undergone for SCCs with invisible surface structure by ME-NBI. Conflict of Interest: None declared.

P506V: PRIMARY ESOPHAGEAL LYMPHOMA: A WINDING PATH TO DIAGNOSIS AND SEARCH FOR A CURE OF COMPLICATION Ekaterina Ivanova1, Evgeny Fedorov2, Ekaterina Tikhomirova2 1

ESOPHAGUS: ENDOSCOPY: ESOPHAGEAL NEOPLASIA P505: PREOPERATIVE DIAGNOSIS OF MAGNIFYING ENDOSCOPY WITH NARROW-BAND IMAGING AND EUS FOR MM/SM1 SUPERFICIAL ESOPHAGEAL SQUAMOUS CELL CARCINOMA Yuji Urabe1, Shiro Oka2, Shinji Tanaka1, Takeshi Mizumoto2, Yoshikazu Yoshifuku2, Kenichi Kagemoto2, Yoji Sanomura1, Kazuaki Chayama2 1 Hiroshima University Hospital, Department of Endoscopy, Hiroshima, Japan and 2Hiroshima University Hospital, Department of Gastroenterology and Metabolism, Hiroshima, Japan

AIMS: Endoscopic resection (ER) is a treatment method for MM/SM1 esophageal squamous cell carcinoma (SCC) as a total excisional biopsy. Recently, Japan Esophageal Society (JES) classification of narrow-band imaging using magnifying endoscopy (ME-NBI) has been proposed. However, diagnostic accuracy of Type B2 has been still controversial. The Aim of this study was to examine and assess the diagnostic accuracy of ME-NBI and endoscopic ultrasonography (EUS) for MM/SM1 SCC. METHODS: 174 esophageal SCCs (pT1a-EP/LPM 124 lesions, pT1a-MM/pT1b-SM1 35 lesions, and pT1b-SM2 15 lesions) resected by ER were enrolled. We examined diagnostic accuracy of ME-NBI and EUS for MM/SM1 SCCs. We estimated the characteristics of diagnosis for MM/SM1 SCCs using MENBI and EUS independently without diagnostic bias each other.

RESULTS: Accuracy of ME-NBI for MM/SM1 was improved from 68% to 76% by considering AVA findings of Type B2. Accuracy of EUS for >30 mm in size was inferior to that for ≤30 mm in size. Accuracy for MM/SM1 did not differ between ME-NBI and EUS. As a result of investigations of misdiagnosed cases by ME-NBI, we identified that roughness of depressed area and coating with white moss might degrade the diagnostic performance of ME-NBI. On the other hand, the lesions of MM superficial invasion, or over 30 mm in size, might induce misdiagnosis of EUS.

Medical Center Klinika K+31, and 2Moscow University Hospital 31, Endoscopy, Moscow, Russia

AIMS: Primary esophageal lymphoma is diagnosed extremely rarely, which poses diagnostic challenges in differentiation with the other esophageal lesions. METHODS: A 63-year old man was admitted to our hospital (Sept 2011) with complaints of dysphagia (grade 2) for 2 years. According to previous EGDs diagnosis varied from erosive esophagitis to advanced ulcerative cancer. Multiple biopsies never confirmed cancer and ranged from tubular adenoma to granulomatous tissues with lymphoplasmacytic infiltration. Upper-GI series and computer tomography showed a stricture of the abdominal esophagus.

RESULTS: Upper GI-endoscopy revealed elongated ulceration suspected to lymphoma 50х10 mm in size and narrowing of the gastro-esophageal junction to 4 mm. EUS showed thickened wall of midthoracic esophagus up to 10–11 mm. Immunohistochemistry - diffuse large B-cell lymphoma. The patient underwent 8 courses of chemotherapy with 2 courses of bougienage with good effect. Nevertheless dysphagia returned in 7 months. Endoscopy revealed a scary stricture in the distal part of esophagus, without any signs of active lymphoma. Considering that the patient could not adequately even drink we decided to perform temporary stenting by self-expandable fully covered metal stent (Niti-S, Taewoong Medical, sized 80x14 mm); in 3 weeks it was removed endoscopically. Dysphagia symptoms decreased, but still occurred in the course of the year. According to the EGDs during 2 years the stricture was up to 8 mm. The health and quality of life has become much better and at the time of the last examination (4 years passed) the stricture became easily traversable and mucosa seemed normal. CONCLUSIONS: Not every huge ulcerated esophageal tumor needs to be a cancer; whereas extremely rare it could be primary lymphoma. No standardized approaches to the management of scary “post-lymphoma” esophageal strictures have been formulated; combination of bougienage and temporary covered SEMS was successful in our case. Conflict of Interest: None declared.




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P507V: ENDOSCOPIC REMOVAL OF RECURRENT CAVERNOUS HAEMANGIOMA OF THE CERVICAL OESOPHAGUS, AS AN ALTERNATIVE TO THE EXTIRPATION OF THE OESOPHAGUS

P508: SUBMUCOSAL TUNNELING ENDOSCOPIC RESECTION FOR UPPER GASTROINTESTINAL MULTIPLE SUBMUCOSAL TUMORS ORIGINATING FROM THE MUSCULARIS PROPRIA LAYER

Evgeny Fedorov, Evgeny Gorbachev, Andrey Shulaev, Anton Zlatovratsky, Pavel Chernyakevich, Ludmila Mikhaleva

Tianying Duan, Yuyong Tan, Yi Chu, Xuehong Wang, Liang Lv, Yuqian Zhou, Deliang Liu

Pirogov Russian National Research Medical University. Moscow University Hospital N 31, Moscow, Russia

The Second Xiangya Hospital of Central South University, Changsha, China

AIMS: Cavernous haemangioma of the cervical oesophagus is a clinical rarity. Possible ethiology of this benign tumour is a vascular, in particular intraoperative, injury.

AIMS: To assess the feasibility, safety and efficacy of submucosal tunneling endoscopic resection (STER) for treating upper gastrointestinal multiple submucosal tumors (SMTs) originating from the muscularis propria layer in a single submucosal tunnel.

METHODS: 70-year old women with severe comorbidity admitted to our hospital with dysphagia (grade 2) and weight loss (12 kg in a year). Two month before admission she underwent endosopic polypectomy in another hospital for 3 cm cavernous haemangioma of the cervical oesophagus, but a month later dysphagia and tumor relapsed. A leading thoracic surgeon twice recommended the extirpation of the esophagus (as it was impossible to exclude a malignant tumor), however the patient refused surgical operation. Two years before admission she underwent selective left parathyroidectomy and resection of the right lobe of the thyroid gland.

RESULTS: CT showed 28x21 mm mass in the cervical oesophagus and narrowed at 85–90% esophageal lumen. According to arteriography the tumor feeds on the left inferior thyroid artery. It was embolized by the spiral with the introduction of the microspheres into esophageal branches for stasis. Transient ischemic cerebral stroke was resolved on day 5 without thrombolytic therapy. Regrettably three month later the dysphagia and 25х20 mm tumour at 20 cm from the incisors persisted. Сonsequently the endoscopic excision of the tumor was made via double-channel videoendoscope by the polypectomy snare with preliminary double ligation of the slightly narrowed after embolization base of the tumour to prevent bleeding. Intraoperative and postoperative complications weren´t observed. The histology confirmed the benign nature of the tumour - cavernous haemangioma with ulceration, severe inflammation and areas of sclerosis. Dysphagia was completely eliminated; the patient gained 12 kg in 9 months; at control EGD 3 and 9 months after endoscopic removal there were no recurrency.

METHODS: From April 2013 to May 2016, a total of 10 patients with upper gastrointestinal multiple SMTs were enrolled in our hospital. All of them were performed with STER and tumors were treated in only one submucosal tunnel. Clinical materials about epidemiological data (name, gender, age), tumor size, procedure-related parameters, complications and follow-up data were retrospectively collected and analyzed.

RESULTS: All of 10 cases were performed with STER smoothly with procedure time range from 45 min to 120 min. A total of 21 submucosal tumors were resected successfully and multiple SMTs of each patient were treated in a single submucosal tunnel. Among 21 SMTs, 18 of them were located on esophagus, and the others were on fundus of stomach. Further, there were 2 lesions in one case presenting on opposite esophageal walls in which tumors were removed via building a tortuous submucosal tunnel. The mean size of all tumors was 1.7 cm (range 0.5–3.8 cm), and 19 of them were revealed leiomyoma in pathology, while 2 SMTs were gastrointestinal stromal tumors (GIST). Common complications of hemorrhage, perforation, and infection were not occurred in all patients intraoperatively or postoperatively. No residual or recurrent lesion was detected during a follow-up of 2 to 38 months. CONCLUSIONS: STER that performed in a single submucosal tunnel is a feasible and efficient method for upper gastrointestinal multiple SMTs originating from the muscularis propria layer, which could benefit patients from avoiding repeated resections. Conflict of Interest: None declared.

CONCLUSIONS: Endoscopic removal of cavernous haemangioma of the cervical oesophagus with preliminary ligation the base of the tumour, can be an alternative to surgical methods of treatment. Conflict of Interest: None declared.


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P509V: ENDOSCOPIC RESECTION FOR ESOPHAGEAL PAPILLOMATOSIS: A CASE REPORT OF A RARE DISEASE re1 Arnaud Lemmers1, Laurine Verset2, Jacques Devie Libre de Bruxelles (ULB), Erasme Hospital, Universite Gastroenterology, Hepato-Pancreatology and Digestive Libre de Bruxelles (ULB), Erasme Oncology, and 2Universite Hospital, Pathology, Brussels, Belgium 1

AIMS: The oncogenic role of human papillomavirus (HPV) is still debated in the development of esophageal squamous cell carcinoma (SCC). Isolated esophageal papilloma is considered benign but few cases of diffuse papillomatosis of the esophagus have been reported to be at risk of neoplastic transformation. Standard management is lacking knowing the scarcity of the disorder. METHODS: We report a video-illustrated case of extended esophageal papillomatosis and its endoscopic management.

RESULTS: A 73-year-old woman underwent a gastroscopy for weight loss. Her past medical history comprises a Biermer disease, hypothyroidism, depression, cholecystectomy, smoking but no alcohol drinking behavior. A gastroscopy revealed diffuse esophageal verrucous polyps (Paris Is-IIa) with pale adherent tissue (IIb) from 28 to 38 cm of the incisors. Biopsies confirmed the presence of a papilloma with high grade dysplasia. An endoscopic staging resection strategy was proposed to the patient. Briefly, a cap-assisted EMR piecemeal resection was performed leading to complete polypoid lesions resection in 7 confluent specimens creating a continuous 10 cm resection area on 50 to 80% of the circumference of the esophagus. Finally, methylprednisolone injections were performed in the submucosa of the resection margins and bed to prevent secondary stricture. The clinical evolution was perfect. Pathological analysis of the specimen revealed two foci of invasive moderately differentiated SCC with a maximal infiltration of the submucosa being sm1 (pT1b sm1). There was neither lymphovascular nor perineural infiltration. Immunolabelling was diffusely positive for HPV p16. Despite clear deep margins, taking into account the risk of lymph node metastasis and the high oncologic risk of recurrence, a surgery was proposed to the patient. CONCLUSIONS: This case illustrates that esophageal papilloma could be associated to neoplastic transformation. Mucosal resection is safe and effective as a staging procedure in this case. Conflict of Interest: None declared.


P510: TRENDS IN THE USE OF STENTS FOR ESOPHAGEAL CANCER AMONG HOSPITALIZED PATIENTS IN THE UNITED STATES: DATA FROM NATIONWIDE INPATIENT SAMPLE 2004–2013 Sravanthi Parasa1, Alessandro Repici2, Sreekar Vennelaganti3, Kevin Kennedy4, Prateek Sharma5 1 Case Western Reserve University, Department of Gastroenterology, Cleveland, USA, 2IRCCS, Milan, Italy, 3 Kansas City VA Medical Center, Kansas City, USA, 4St Luke’s Hospital, Kansas City, USA and 5Kansas City VA Medical Center, Department of Gastroenterology, Kansas City, USA

AIMS: To evaluate the trends in the use of stents for Esophageal Cancer and complications associated with it in the United States over the past decade. METHODS: Data were obtained from the Nationwide Inpatient Sample from years 2004–2013, the largest all-payer discharge database in the United States. International Classification of Disease (ICD–9) codes were used to identify patients with EC who underwent esophageal stent placement and these patients were included in the analysis. ICD-9 codes were also used to assess short -term outcomes of these patients. Complications of esophageal stenting including esophageal perforation, esophageal hemorrhage, stent migration were determined and factors associated with these complications was studied using multivariate logistic regression analysis. Odds Ratios were calculated adjusting for relevant patient factors.

RESULTS: Of 545,642 patients admitted with an underlying diagnosis of EC during 2004 to 2013, a total of 14,152 patients underwent esophageal stent placement. There was a slow but statistically significant uptrend in the use of esophageal stents, with 1105 (2.3% of EC patients) in 2004 to 1695 (3.0% of EC patients) in 2013 (P-trend 6) in 56 patients (61.54%). Level of Mp53 expression increased significantly with increasing histological grades of ESCC and TNM stage (P =< 0.001). Survival at1 year in Mp53 high expression group is 67.86% (SE = 0.0473, CI = 0.75–0.97) and in Mp53 low expression group is 91.43% (SE = 0.06, CI = 0.53–0.78) with statistically significant difference in these groups (P < 0.0001). CONCLUSIONS: Expression of Mp53 in esophageal squamous cell carcinoma showed positive correlation with increasing histological grade, and TNM stages. High Mp53 expression group has significantly low survival than low Mp53 expression group, suggesting that immunohistochemical analysis of Mp53 is simple & effective modality to determine the prognosis and survival in ESCC. Conflict of Interest: None declared.

ESOPHAGUS: ENDOSCOPY: ESOPHAGUS OTHER P516: PROSPECTIVE STUDY OF FOREIGN BODIES IN ESOPHAGUS Ramila Shrestha, Dinesh Shrestha, Amrendra Mandal, Mukesh Paudel Bir Hospital, Gastroenterology, Kathmandu, Nepal

AIMS: Foreign bodies in esophagus cause significant morbidity. Optimum method of their removal depends on the availability of resources and expertise. Rigid and flexible endoscopy techniques appear to be safe and effective in their retrieval. We report outcomes of 83 patients with impacted food and other foreign bodies in the esophagus. METHODS: This is a prospective observational study carried out in department of gastroenterology, Bir hospital, Kathmandu, Nepal; over a period of seven years (2008–2014). Patients who presented with complains of dysphagia and history of foreign body ingestion were included in the study. Patients underwent a upper gastrointestinal endoscopy procedure without anesthesia. The demographic profile of patients


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was collected and data was collected regarding the nature and location of foreign bodies.

RESULTS: Eighty three patients underwent endoscopy for foreign bodies. Forty eight (57.8%) were males. The commonest age of presentation was in fifties (n = 15, 18%). Most of the patients (40.9%) presented within 24 h of ingestion. Organic food materials constituted the majority (85.5%). Forty six (55.4%) ingested chicken bone and 17 (20.4%) had ingested chicken meat. Number of patients ingesting wires and dentures were four each. Number of patients who ingested safety pin, button and stone was one each. With flexible endoscopy, removal of foreign bodies was done in 69 patients (83.1%). Surgery was required in five patients (6%) and in nine patients (10.8%) the foreign body was pushed into the stomach. One patient developed trachea-esophageal fistula, three had single ulceration in esophagus and one had circumferential ulcer in esophagus. CONCLUSIONS: In patients with impacted foreign bodies of esophagus, removal with flexible endoscopy is a safe procedure with good success rate and limited complications. This study paves the way for future research regarding comparison of flexible endoscopy with other methods of foreign body removal like rigid endoscopy, use of foley catheter and esophageal bougienage. Conflict of Interest: None declared.

P517V: BREAKING THE WEB: A CASE OF PLUMMER VINSON SYNDROME IN THE PHILIPPINES Ma. Marylaine Dujunco, John Arnel Pangilinan, Joseph Bocobo St. Luke’s Medical Center, Institute of Digestive and Liver Diseases, Quezon City, Philippines

AIMS: Plummer Vinson syndrome (PVS) is an extremely rare disease characterized by the triad of iron deficiency anemia, dysphagia and cervical esophageal web. The most accepted possible etiology of this syndrome is iron deficiency anemia. The prevalence of anemia in third world countries is high and yet there is no published case to date of PVS in the Philippines. This case presents a Filipino with PVS managed endoscopically followed by iron supplementation. METHODS: We report a case of a 44 year old female, Filipino with two decades of iron deficiency anemia, a decade of dysphagia with a cervical esophageal web on esophagogastroduodenoscopy (EGD).

RESULTS: After EGD with mechanical dilatation, dysphagia was resolved and patient now is able to eat a full regular meal. She was given iron supplementation and advised annual esophagogastroduodenoscopy. CONCLUSIONS: The triad of iron deficiency anemia, dysphagia and cervical esophageal web is Plummer Vinson syndrome which can be readily managed by iron supplementation, and


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esophageal dilatation. Patients need to be on annual surveillance EGD due to risk for esophageal or pharyngeal malignancy. Conflict of Interest: None declared.

P518: STUDY ON THE INCIDENCE OF EOSINOPHILIC ESOPHAGITIS IN KING GEORGE HOSPITAL, VISAKHAPATNAM Sravan Korrapati1, Kiran Repana2, Murali Krishna Palakurthi1, Girinadh Lrs1 1 Andhra Medical College, Department of Gastroenterology, and 2Andhra Medical College, KGH, Department of Gastroenterology, Visakhapatnam, India

AIMS: As there is growing literature on eosinophilic esophagitis in the west and scarce data regarding the prevalence or incidence in India, we aimed at evaluating the incidence of EoE in our hospital. METHODS: Patients presenting with symptoms of GERD (n = 71) from Dec 2014 to Feb 2016 where subjected to upper GI endoscopy and biopsy of esophagus at both proximal and distal ends. Biopsy samples were subjected to HPE for the presence of eosinophilis. If >20 eosinophils/HPF have been found on HPE they are subjected to 8 week course of PPI therapy and repeat biopsy was done. If their biopsy showed persistent eosinophils >20/HPF a diagnosis of EoE was made.

RESULTS: Of the 71 patients, males were 54% (n = 39), mean age was 40.4 years. One patient showed endosopic features suggestive of EoE. Only 2 patients had few eosinophils in the HPE but not diagnostic of EoE.

septic arthritis. A gastroscopy revealed a pseudo-tumor of the upper esophagus. Biopsies exluded any neoplasia and confirmed histologic findings compatible with esophagitis dissecans superficialis. Clindamycin treatment was interrupted and pantoprazole 40 mg b.i.d given to the patient, with excellent clinical evolution and endoscopic healing at 8 weeks. Esophagitis dissecans superficialis (EDS) is a rare desquamative disorder of the esophagus, characterized by sloughing of the superficial mucosa. It is a benign entity of uncertain etiology. Most cases of EDS are idiopathic but can be caused by medications (mostly psychoactive drugs), hot beverages, chemical irritants, celiac disease, collagen diseases and skin conditions. Pathogenesis remains unknown. It might represent a common reaction of esophageal squamous mucosa to various types of insult (physical, chemical, thermal and immunological) or topical allergic response. The endoscopic features of EDS range from single or multiple, white patches of peeling mucosa, extending from the mid to the distal esophagus to diffuse sloughing of the entire esophageal mucosa. The histologic findings in EDS is a sloughing of the superficial squamous epithelium with occasional bullous separation of the layers, parakeratosis and varying degrees of acute or chronic inflammation, fungal elements may be associated. Our case is the second described in the literature of EDS induced by Clindamycin.

CONCLUSIONS: This case report highlights the importance of considering EDS in the differential diagnosis of a candidiasis, lichen planus and squamous cell carcinoma of the esophagus and to consider clindamycin as potential causative agent of EDS. Conflict of Interest: None declared.

CONCLUSIONS: During our study period we couldn’t find a single case of EoE. Conflict of Interest: None declared.

P520: UPPER GI BLEEDING WITH HEMORRHAGIC SHOCK CAUSED BY INFECTIOUS ESOPHAGITIS-CASE REPORT

P519: UNUSUAL ENDOSCOPIC PRESENTATION OF ESOPHAGITIS DISSECANS SUPERFICIALIS INDUCED BY CLINDAMYCIN. A CASE REPORT

Madalina Ilie1, Gabriel Constantinescu2, Raluca Stanciulescu3, Valentin Enache4, Daniela Tabacelia5

1

1

2

Elias Fiani , Francois Guisset , Nicky D’haene , Arnaud re1 Lemmers1, Jacques Devie Libre de Bruxelles), Erasme Hospital, ULB (Universite Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, and 2Erasme Hospital, ULB (Universite Libre de Bruxelles), Pathology Department, Brussels, Belgium 1

AIMS: To improve the knowledge of a rare desquamative disorder of the esophagus with an illustrated case. METHODS: Case report and review of the literature. RESULTS: An 83 years old female presented with symptoms of dysphagia 2 days after she started Clindamycin treatment for

1

UMF Carol Davila/Clinical Emergency Hospital Bucharest, Clinical Emergency Hospital Bucharest, Gastroenterology, 3 Sanador Hospital, Gastroenterology, 4Clinical Emergency Hospital Bucharest, Pathology, and 5Clinical Emergency Hospital Bucharest, Bucharest, Romania 2

AIMS: Massive gastrointestinal bleeding is rarely caused by infectious etiologies especially with esophageal localization. Even if Cytomegalovirus infection (CMV) is not often encountered in the clinical practice, it has to be taken into account when the cause of GI hemorrhage is not obvious. METHODS: We report a case of a 53 years old, male patient, with diabetes who is admitted in the hospital for cellulitis of the left calf. Arteriography of the femoral artery and amputation of the three toes is performed. After 10 days of hospitalization, the patient develops massive hematemesis but the upper GI


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 endoscopy reveals a large number of clots in the esophagus with no obvious source. The control endoscopy shows erosions and erythema in the lower third of the esophagus with no blood. The patient is treated conservatory with PPI and blood transfusions. He is apparently well but after 5 days a new episode of massive hematemesis is encountered with severe hypotension and drop of hemoglobin to 6 g/dL. The endoscopy is performed in the ICU department with the patient intubated and it reveals deep ulcers and erythema throughout the esophagus. Multiple biopsies from esophageal mucosa are taken.

RESULTS: We suspect viral esophagitis with CMV and we are starting empiric treatment with Valganciclovir 900 mg/day for 21 days. The clinical course is favorable with no repeated episode of bleeding. The surprise is coming from our pathology department which confirms the presence of granular intracytoplasmic inclusion bodies imparting the characteristic of “owl´s eye” appearance. CONCLUSIONS: Cytomegalovirus infectious esophagitis causing upper GI bleeding with hemorrhagic shock is rarely reported in the literature. We should consider this etiology in immunocompromised patients with non-peptic ulcerative esophagitis. Initiation of early antiviral treatment even without histology represents the key of therapeutic success being lifesaving. Conflict of Interest: None declared.


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frequency endoscopic ultrasonography (EUS) and deep forceps-biopsy. Mean tumor size was 0.8 cm. In 3 patients ESD with DualKnife and hydroxyethyl starch solution was performed, while in other 8 and 2 we used snare-EMR and cap-assisted EMR respectively, as endoscopic treatment techniques.

RESULTS: All tumors were dense yellow-coloured lesions, originating from submucosa and hypoechoic, according to EUS data. In 10 of them mucosa was fixed to tumor mass, but only in 3 cases pre-treatment biopsy confirmed granular-cell tumor. High definition NBI showed enlarged, but not distorted intrapapillary capillary loops (IPCL) in 8 cases, in 5 patients IPCL’s were intact. There were no complications in all cases of endoscopic treatment and, also, no recurrence, neither after EMR, nor after ESD. CONCLUSIONS: In our study we have defined endoscopic and endosonographic diagnostic criteria of esophageal granular-cell (Abrikosoff) tumors. Cap-assisted, snare EMR or ESD are valuable treatment techniques in such patients. Conflict of Interest: None declared.

P522: EVALUATION OF THE FREQUENCY OF RENOVASCULAR IMPEDANCE AND ITS RELATIONSHIP WITH THE PRESENCE OF ESOPHAGEAL VARICES IN PATIENTS WITH CHILDPUGH CLASS A CIRRHOSIS WITHOUT ASCITES

P521: ENDOSCOPIC DIAGNOSTICS AND TREATMENT OF ESOPHAGEAL GRANULAR-CELL TUMORS

Essam Ali Hassan Soliman1, Tawfiek Mohamed2, Wael Fathi Elsayed2, Ahmed Ali Gomaa3, George Ayad Malak2, Alaa Abdou2

Sergey Pirogov1, Viktor Sokolov1, Andrey Kaprin2, Dmitry Sukhin1, Dmitry Sokolov1, Elena Karpova1, Nadejda Volchenko3, Andrey Ryabov4, Vladimir Khomyakov4, Vadim Cheremisov4

Fayoum University, Tropical Medicine, Fayoum, Egypt, Beni Swief University, Beni Swief, and 3Fayoum University, Fayoum, Egypt

1

AIMS: The aim of this work was evaluation of the frequency of increased renovascular impedance and its relationship with the presence of esophageal varices in patients with Child-Pugh class A cirrhosis without ascites and the possibility of its use as a predictor factor of esophageal varices.

P.A. Herzen Moscow Oncology Research Institute, Endoscopy, 2P.A. Herzen Moscow Oncology Research Institute, 3P.A. Herzen Moscow Oncology Research Institute, Pathology, and 4P.A. Herzen Moscow Oncology Research Institute, Thoracic & Abdominal Surgery, Moscow, Russia

1

2

METHODS: This study was done on 50 patients with child A AIMS: Granular-cell (Abrikosoff) tumors rarely detected in esophagus, due to misdiagnosis. More often in such cases conclusion of endoscopic examination stating as lipoma, leiomyoma or “esophageal polyps”. But really, Abrikosoff tumors are not so rare, and more than 30% of them occurs in esophagus. The main aim of our study was to define endoscopic diagnostic criteria of such tumors and to estimate the results of it´s endoscopic treatment

METHODS: In P.A. Herzen Moscow Cancer Research Institute last two years 13 cases of granular-cell tumors in esophagus were confirmed. Mean patient age was 53 years, 10 of 13 patients were female. In all cases comprehensive endoscopic diagnostics was performed, including white-light endoscopy, high-definition narrow-band imaging (NBI) endoscopy, high

liver cirrhosis attended to the outpatient clinic of endemic medicine department in Beni-suef university hospital. All patients were subjected to complete history taking, thorough clinical examinations, laboratory investigations, abdominal ultrasonography and Doppler study of the portal and renal vessels. Upper endoscopy was done for all the patients.

RESULTS: In our study there is significant correlation between increase of RRI and presence of varices. In our study the Sensitivity, Specificity, Positive predictive value and Negative predictive values of renal resistive index are 53.8, 95.8, 93.3 and 65.7%.


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In our study the Sensitivity, Specificity, Positive predictive value and Negative predictive values of portal congestive index are 7.6, 95.8, 66.6 and 48.9%.

CONCLUSIONS: The Laboratory data analysis in the current study showed that there is no significant correlation between thrombocytopenia and presence of varices. There is significant Correlation between Spider naevi and grading of esophageal varices while there wasn´t significant Correlation between Spider naevi and presence of esophageal varices. There is significant Correlation between Splenic hilar collaterals and presence of esophageal varices and also with grading of esophageal varices. Conflict of Interest: None declared.

P523: N-ACETYLCYSTEINE-INDUCED ESOPHAGITIS: A CASE REPORT Weihong Wang, Lei Xu, Yi Liu, Yu Zhang, Dingmei Shi Ningbo No.1 Hospital, Ningbo, China

P524V: ENDOSCOPIC FENESTRATION OF AN ESOPHAGEAL BRONCHOGENIC CYST Arnaud Lemmers1, Daniel Blero2,3, Aous Ouazzani4, Pierre Eisendrath2, Vincent Huberty2, Marianna Arvanitaki2, Mostafa Ibrahim2, Laurine Verset5, Olivier Le Moine2, re2 Jacques Devie Libre de Bruxelles (ULB), Erasme Hospital, Universite Gastroenterology, Hepato-Pancreatology and Digestive Libre de Bruxelles (ULB), Oncology, Brussels, 2Universite Erasme Hospital, Gastroenterology, Hepatopancreatology Libre de and Digestive Oncology, Brussels, 3Universite Bruxelles (ULB), ISPPC, Gastroenterology, Charleroi, 4 Libre de Bruxelles (ULB), ISPPC, Visceral Surgery, Universite Libre de Bruxelles (ULB), Erasme Charleroi, and 5Universite Hospital, Pathology, Brussels, Belgium 1

AIMS: Esophageal bronchogenic cysts are thought to be congenital lesions arising from the primitive foregut with abnormal budding. We sought to describe the mini-invasive treatment in this rare abnormality. METHODS: We report a video-illustrated case of esophageal bronchogenic cyst treated by endoscopic fenestration.

AIMS: To report an unusual case that severe chest pain caused by N-acetylcysteine-induced esophagitis.

METHODS: A case of N-acetylcysteine-induced esophagitis in an old man were reviewed.

RESULTS: An 81-year-old yellow man with a history of interstitial lung disease was admitted to our hospital with arrhythmia that began 5 days earlier. The patient had complaints of cough, sputum, and shortness of breath. Cefminox injections and Nacetylcysteine tablets were prescribed to improve respiratory symptoms. The patient developed severe chest pain and odynophagia 4 h after swallowing the N-acetylcysteine tablet while in the decubitus position. Upper gastrointestinal endoscopy revealed four discrete areas of ulcerations measuring approximately 1 cm at the mid-esophageal level. The distance between the foci and the incisors was approximately 24 cm. The patient continued oral the N-acetylcysteine, which was administered in powdered form with more water while in the upright position; Pantoprazole and hydrotalcite were also given. The symptoms subsided, and a follow-up endoscopy after 20 days showed that the ulcers had healed. CONCLUSIONS: N-acetylcysteine might induce esophagitis. Conflict of Interest: None declared.

RESULTS: An 83-year-old woman presented with progressive dysphagia and 12 kg weight loss. Thoracic CT and esophagogram demonstrated an external compression of the lower esophageal lumen by a mediastinal cyst. A surgery by thoracotomy was tried two years before without any improvement of symptoms. Endoscopic Ultrasound demonstrated an 8 cm long cyst with heterogeneous content surrounded by a multilayer wall and a suspicion of fusion of the layers with the esophageal wall. The proposed diagnostic was an esophageal duplication cyst. An endoscopic fenestration was performed. Under EUS control, cystic location was precisely identified. After submucosal fluid injection, a TT-knife (Olympus, Japan) was used to mark the distal part of the cyst and then to open it by transmural cutting. Some pus was aspirated from the cyst. Using a duodenoscope, an IT-knife (Olympus) was then used for its insulated tip to open on 2 cm from bottom to top the wall of the esophagus and widely open cyst for fenestration. Six weeks later, patient symptoms had resolved. An extension of the fenestration length was performed with edge clipping to maximize the chances of long-term symptoms control. At one year, the patient was still symptom-free. A gastroscopy disclosed the persistence of a wide opening of the neodiverticulum without any food content. Biopsies of the internal epithelium of the cyst were compatible with a bronchogenic cyst. CONCLUSIONS: This report provides additional evidence that endoscopic fenestration of esophageal bronchogenic cyst might be a safe and effective procedure in certain cases. Conflict of Interest: None declared.




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P525: SUCCESSFUL ENDOSCOPIC MANAGEMENT OF ESOPHAGEAL PERFORATION AND EMPYEMA SECONDARY TO IMPACTED DENTURE

virus (HIV) -related multiple esophageal stricture that was treated endoscopically.

Deepak Lahoti

food dysphagia and weight loss. He was diagnosed with AIDS eight-years ago and was treated with anti-retroviral (ART) therapy. He was non-compliant to treatment and developed multidrug-resistant strain of HIV. His CD4 count was 8 cells/μl and HIV viral-load was 38,457 IU/mL. Computerised tomography of the thorax and abdomen demonstrated thickening of oesophagus. An upper endoscopy (OGD) showed multiple smooth benign-appearing stricture starting from 25 cm of esophagus to gastro-esophageal junction. Multiple small discrete ulcer were seen between strictures. Biopsy from the strictures and ulcer showed no evidence of cytomegalovirus, mycobacteria, herpes simplex virus and fungal infection. A presumptive diagnosis of HIV-related esophageal ulcer and stricture was made and ART was restarted. He was well until four weeks when he presented with severe dysphagia.

Max Superspecialty Hospital, Patpar Ganj, Gastroenterology, New Delhi, India

AIMS: Esophageal perforations, spontaneous or iatrogenic are associated with high morbidity and mortality rates, particularly in patients with mediastinal and pleural contamination and delayed intervention. Surgery has high morbidity and mortality. Esophageal stent placement has been described as a promising modality in the management of these conditions. To evaluate the usefulness of fully covered stent in management of esophageal perforation, mediastinitis and empyema induced by an impacted denture. METHODS: 57-M presented with chest pain and fever. He accidentally ingested a denture few days back but remained comfortable except mild pain during swallowing. His blood counts were elevated An x-ray. chest and a CECT scan showed huge right sided pleural effusion. A tube was placed in the pleural cavity which drained food material and pus. An upper GI endoscopy was done which showed a denture in the esophagus which slipped soon into the stomach. The denture was retrieved endoscopically. An about 1 cm perforation was noted in the mid esophagus. A 15 cm covered esophageal stent (Boston Scientific) was placed under endoscopic and fluoroscopic control. Patient was allowed orally the next day.

RESULTS: The patient gradually improved. Serial imaging showed complete resolution of empyema. A contrast esophagogram showed complete haling of the perforation The stent was removed after 8 weeks with complete resolution of dysphgia. One year followup showed no recurrence of dysphagia or chest infection.

METHODS: A 44-year-old male with AIDS presented with solid

RESULTS: An OGD showed progression of the previous esophageal stricture at 25 cm resulting in a “pin-point“ lumen. The ulcers seen have healed completely. Barium meal demonstarted a 1 cm long critical stricture and multiple distal strictures in the esophagus. The stricture was then dilated twice at two weeks interval using polyvinyl dilator to 11 mm. The stricture remained “pin-point” despite dilatation. We repeated serial dilatation using balloon dilator to a maximum diameter of 13.5 mm. However, the “pin-point” stricture recurred within 4 weeks causing persistent symptoms. We then placed a 18 mm x 120 mm partially covered selfexpandable metal stent which traversed all the strictures. There were no complications and his symptoms improved significantly. CONCLUSIONS: Refractory esophageal stricture secondary to HIV is rare. Our video demonstartes the different technique used for treatment of benign esophageal stricture. Conflict of Interest: None declared.

CONCLUSIONS: Placement of a covered stent is useful in management of denture induced esophageal perforation, mediastinitis & empyema and can avoid surgery with its morbidity and mortatity. Conflict of Interest: None declared.

P527: TOPICAL MITOMYCIN C TREATMENT FOR RELIEVING ESOPHAGEAL RADIATION-INDUCED STENOSIS Zhining Fan1,2, Lili Zhao1, Xiang Wang1, Li Liu1, Min Wang1 1

P526V: ENDOSCOPIC TREATMENT OF AN UNCOMMON OESOPHAGEAL STRICTURE Ravishankar Asokkumar, Steven Mesenas Singapore General Hospital, Department of Gastroenterology and Hepatology, Singapore, Singapore

AIMS: Esophageal involvement from opportunistic infection is a common complication in patient with Acquired immunodeficiency syndrome (AIDS). However, occurrence of esophageal stricture is rare. We report a case of human immunodeficiency

The First Affiliated Hospital of Nanjing Medical Universtiy, Jiangsu Province Hospital, Nanjing, China

2

AIMS: Radiation-induced stenosis is common after esophageal cancer treatment, especially at proximal esophagus. Instead of stent placement, endoscopic dilation combined with topical mitomycin C treatment has been reported to improve benign esophageal dysphagia. This study was designed to evaluate the safety and efficacy of this strategy for radiation-induced stricture. METHODS: Patients with esophageal strictures were divided into 2 groups, including dilation in association with mitomycin C


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injection (mitomycin C group) and dilation in association with saline injection (dilation group). Patients´ age, sex, type of stricture, stricture location, number of previous dilations, diameters before and after dilation, and dysphagia-free period were compared.

RESULTS: A total of 17 patients were enrolled into this study, including 7 in mitomycin C group and 10 in dilation group. There were no significant difference in baseline characteristics of patients, such as age, sex, type of stricture, stricture location, and number of previous dilations. The major complication was one patient in mitomycin C group with perforation (P < 0.05). The minor complications were reported for 4 in mitomycin C group, and 6 in dilation group (P > 0.05). The mean dysphagiafree period was 6.33 1.48 months in the mitomycin C group, and 3.26 1.13 months in the dilation group (P < 0.05).

CONCLUSIONS: Endoscopic dilation combined with topical mitomycin C therapy could prolong the esophageal dysphagiafree period and reduce the frequency of endoscopic dilation, which would be the potential strategy for refractory esophageal stricture. Conflict of Interest: None declared.

procedure included endoscopic removal, prompt placement of Sengstaken-Blakemore tube (SBT), adjustable balloon inflation for compression hemostasis, necessary surgery and postoperative intensive care.

RESULTS: Fish bone was successfully removed without sever complication. The patient was discharged one week later. CONCLUSIONS: Endoscopic strategy was also safe, effective and reliable for managing high-risk foreign body, innovatively combined application of SBT. More clinical studies are required to standardize the protocol and promote its clinical application. Conflict of Interest: None declared.

ESOPHAGUS: ENDOSCOPY: GASTROESOPHAGEAL REFLUX (GERD) P529: SLEEP APNEA (SA) IN THE DIFFERENT FORMS OF GERD ASSOCIATED WITH CAD Olena Izmailova1, Olena Krakhmalova2 1

P528V: ENDOSCOPIC RETRIEVAL AND FLEXIBLE COMPRESSION HEMOSTASIS FOR MANAGING ESOPHAGEAL FOREIGN-BODY INGESTION WITH HIGH-RISK AORTIC INJURY Zhining Fan, Chenguang Dai, Lili Zhao, Min Wang The First Affiliated Hospital of Nanjing Medical University, Nanjing, China

AIMS: Ingestion of foreign body is one of the most common endoscopic emergencies. 10–20% cases need endoscopic interventions, while only 1% or less require surgical intervention. Esophagus is the most common location for getting foreignbody stuck, especially fish bones. Fish bones often might result in esophageal erosion, perforation, mediastinitis, pseudoaneurysm, and even injuries to the aorta or aorta-esophagus fistulae. In the cases with aortic injury or aorta-esophagus fistulae, placement of endovascular stent, bridging TEVAR and sequential cardiothoracic surgery usually take the prominence. Here, we introduced the novel application of endoscopy and SBT for safely retrieving foreign fish bone.

METHODS: Recently, a 44-year-old woman with continuous chest pain after eating fish was referred to our hospital. Endoscopy and contrast-enhanced computed tomography (CECT) confirmed a fish bone was entrapped in the esophagus at the level of the crossing main bronchus. CECT demonstrated that it pierced the esophageal wall and was close to adventitia of descending aorta, which might lead to unconfirmed aorta injuries, even aorta-esophagus fistulae. Due to her rejection for surgery, endoscopic retrieval combined with necessary surgical management was applied for her. Key points of the successful

Government Institution, L.T. Malaya Therapy National Institute of the National Academy of Medical Sciences of Ukraine, Gastroenterology, and 2Government Institution, L.T. Malaya Therapy National Institute of the National Academy of Medical Sciences of Ukraine, Cardiopulmonology, Kharkiv, Ukraine

AIMS: To determine whether SA severity depends on the form of GERD and on the course of CAD in the GERD and CAD comorbidity. METHODS: The 65pts with a combination of GERD and CAD was studied, men 83% and women 17%, Me-63 years. Prescription GERD was from 0.5 to 11 years; Me - 4 years. Prescription CAD - from 3 months to 21 years; Me - 6 years. The patients were divided into2 groups: I- 21 pts with NERD and II - 44 pts with erosive GERD. To detect SA a diagnostic system SOMNOcheck micro was used. The apnea-hypopnea (AHI), obstructive (OAHI), autonomic arousal (AAI) and cardial risk (CRI) indexes were assessed.

RESULTS: Mild SA was diagnosed in 90.9% pts of group I vs 73.0% pts of group II; moderate SA- in 9.1% pt. of group I vs 16.2% pts of group II; severe SA - in 10.8% pts of group II only. In the group I the AHI was 5 (5¸8) vs 10 (7¸22) in group II (P < 0.01), OAHI = 3 (3¸5) vs 5 (4¸18) in group II (P < 0.01); AAI = 5 (4¸12) vs 13 (7¸23) in group II (P < 0.05); CRI = 0 (0,0.1) vs 0.31 (0.01, 0.82) in group II, (P < 0.01). In the group I a correlation was found: АНI & BM) (r = 0.69; P < 0.01); АНI& the age (r = 0.52; P = 0.02); АНI & the prescription of NERD (r = 0.5; P = 0.02); oAHI & the prescription of CAD (r = 0.5; P = 0.03); oAHI & the prescription of NERD (r = 0.5; P = 0.03). In the group II the correlation was found: CRI & the prescription of GERD (r = 0.3; P = 0.05); CRI & the prescription of CAD (r = 0.42; P < 0.01); OAHI & BMI (r = 0.41; P < 0.01).


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 CONCLUSIONS: The SA was less expressed in NERD compared erosive GERD. The severity of SA in both groups was associated with BMI, age, GERD and CAD prescriptions. Conflict of Interest: None declared.


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P531: TREATMENT OF GERD USING STRETTA RADIOFREQUENCY: AN OBSERVATIONAL CASE CONTROLLED STUDY Rakesh Kalapala, D. Nageshwar Reddy

P530: THE FREQUENCY OF COLUMNAR-LINED ESOPHAGUS IN PATIENTS WITH GERD


Olena Krylova

AIMS: Gastroesophageal reflux disease (GERD) is the most common chronic GI disorder affecting one third of the population worldwide. Recently, there has been a renewed interset in STRETTA therapy in view of potential long term side effects of PPI’s and the durability of relief with Fundoplications.

Institute of Gastroenterology of National Academy of Medical Science of Ukraine, Dnepropetrovsk, Ukraine

AIMS: GERD is a global disease and its prevalence is increasing. Barrett´s esophagus (BE) refers to the endoscopic presence, confirmed histologically, of columnar-lined esophagus (CLE). This is currently the only identifiable complication of GERD that is known to have malignant potential. That why our aim was to examine the frequency of CLE in patients with GERD. METHODS: 74 examined patients with GERD, median age (45.3 3.5) years, 40.5% men, 59.5% women. Endoscopy was performed in connection with treatment failure (21), in patients with multiple risk factors BE (9), who have had GERD for more than 5 years (18), in the presence of extraesophageal manifestations (14), hiatal hernia (12). Endoscopy was performed by EVIS EXERA III, GIF-HQ190 with NBI, magnification, chromoscopy of 0.2% indigo carmine, 3.0% acetic acid.

RESULTS: 31 patients of 74 had CLE (41.9%), from these patients 71.0% had less than 1 cm length of CLE - (0.34 0.07) cm, so that it was CLE in esophago-gastric junction. The short segment CLE was set at 22.6% (7 patients) (1.7 0.2) cm, the long - 6.5% (2 patients) (9.0 1.0) cm. CLE structure in most patients had oval type with elongated crests, in only one case a flat type of mucosa with long branched vessels was revealed. All patients underwent chromoscopy, magnification and NBI and Light blue crests (LBC) were set at 3 patients (9.7%), the presence of which correlates with intestinal metaplasia, that was confirmed histologically. LBC and intestinal metaplasia revealed at 2 patients with multiple risk factors of BE and a patient with a 7-year course treatment of GERD. CONCLUSIONS: It is necessary to perform endoscopy with NBI, magnification and chromoscopy to identify CLE and BE at patients with longer duration of GERD and multiple risk factors of BE. Conflict of Interest: None declared.

METHODS: Observational case control study comparing the Stretta treatment with controls receiving PPIs. Patient (>18 years, N = 20) with symptoms of heartburn, regurgitation, abnormal esophageal acid exposure (≥4%) and endoscopically confirmed esophagitis were included into the study. The primary measure was improvement in quality of life (QOL) and decrease in the frequency and severity of GERD symptoms.

RESULTS: The mean age of the patients was 36–45 years. Three months after Stretta, 80% reported improvement in QOL compared to 40% in the control group. At the end of 3 months, significant (P < 0.05) improvement in GERD symptom score for heartburn, regurgitation, chest pain and cough compared with control group was observed. After Stretta treatment, 60% of patients were free of PPIs whereas there was no change in the control group. Almost 80% patients on STRETTA treatment were satisfied with the treatment compared to 30% patients in the control group. CONCLUSIONS: This study shows that STRETTA is an effective procedure for the management of GERD and can be considered for patients who are not satisfied with pharmacologic therapy. Conflict of Interest: None declared.

P532: ACID SENSITIVITY IN NONEROSIVE REFLUX DISEASE (NERD) Ahmed Ali Gomaa1, Samy Zaky2, Essam Ali Hassan Soliman1, Esmat Sheba3, Ibrahim Nagm2, Nabil Gad Elhak4, Hamdy Abdel Satar2, Khalid Abdel Hafeiz2, Nabil Alnomani2 1 Fayoum University, Fayoum, 2Al Azhar University, Facuaty of Medicine, Cairo, 3Cairo University, Cairo, Egypt and 4 Mansoura University, Mansoura, Egypt

AIMS: To study the acid sensitivity in nonerosive reflux disease (NERD). METHODS: Thirty persons suffering from reflux symptoms were enrolled in the study. Fifteen patients (Group I), had, mucosal injury by endoscopic examination. Group II, (15 patients) didn´t have esophageal mucosal injury “normal esophagus endoscopic examination”. All patients were subjected to upper endoscopic examination, esophageal


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manometric study, ambulatory esophageal pH monitoring and sensitivity test by instillation of different concentration of acid.

RESULTS: The most frequent symptoms in both groups were heartburn “100%” and regurgitation “40%”. There were insignificant differences between both groups in all parameters of the motility study except in LES pressure that was significantly lower in GERD group than NERD group. There was insignificant difference between GERD and NERD groups in reflux times but the number of reflux episodes was significantly higher in GERD group than NERD group. Ten (66.6%) GERD patients perceived acid at moderate concentrations (6 at pH 4; 4 at pH 5) vs to 8 (53.3%) NERD patients (5 at pH4; 3 at pH 5). One (6.7%) GERD and 4 (26.7%) NERD perceived low acid concentrations (pH 7 and 6 respectively). There was positive correlation between 1st acid sensitivity (1st sensation) and number of long reflux episodes in GERD group. Still some patients with typical GERD symptoms have normal endoscopy, normal acid exposure and normal acid sensitivity. CONCLUSIONS: The number of reflux episodes was significantly higher in GERD group than NERD group. There was positive correlation between 1st acid sensitivity (1st sensation) and number of long reflux episodes in GERD group. Still there is another factor/s responsible for the NERD symptoms rather than acid exposure or hypersensitivity to acid and some patients may have non-acid intra-esophageal stimuli that trigger typical heartburn. Conflict of Interest: None declared.

P533: EFFICACY AND SAFETY OF THE ENDOLUMINAL MANAGEMENT OF REFRACTORY GASTROESOPHAGEAL REFLUX WITH BAND LIGATION Waseem Seleem, Amr Hanafy Zagazig University, Internal Medicine - Gastroenterology Unit, Zagazig, Egypt

AIMS: About 10–40 % of patients with GERD fail to show adequate symptomatic response to the standard dose PPI. The aim was to evaluate the safety and efficacy of endoluminal rubber band ligation in the management of refractory GERD. METHODS: 20 patients were treated with rubber band ligation and the cap used for ligation has a diameter of 11 mm and loaded with 6 rings. The main outcome is reduction of reflux symptoms measured by GERD health related quality of life Questionnaire. Patients included if showed typical symptoms of heartburn or regurgitation refractory to maximally optimized dose of PPI. Patients excluded if they had lower esophageal ulcers, pregnancy, red flag signs as loss of weight, fever, dysphagia, odynophagia, bleeding. Large hiatal hernia more than 2 cm, paraesopgageal hernia, active Helicobacter pylori infection, eosinophilic esophagitis were also excluded. Band ligation was performed in the four quadrants 5 mm distal to the Z-line which was measured before and after the sessions were completed.

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 RESULTS: 13 males and 7 females were enrolled in the study. Their mean age 39.5 6.2 years, pre-endoscopic mean hemoglobin10.6 0.9 gm/dL, mean GERD related quality of life questionnaire (GERD-QLQ) value was 35.4 6.9, depth of Zline 34 1.1 cm, frequency of the sessions needed 1.6 0.6 times over 4 months. After 6 months of follow up, GERD-QLQ score had dramatically improved 15.4 4.6 (t = 11.85, P = 0.000), depth of Z line became 35 0.9 cm (t = –3.2, P = 0.005), hemoglobin level showed non-significant increase (10.9 0.8 gm/dL, P = 0.06). 5 patients developed mild dysphagia improved after 6.5 2.2 days, 8 patients (40%) experienced mild epigastric pain which improved after 5.4 1.5 days. 13 patients stopped PPI use (65%), 6 patients were on demand therapy (30%), and only one patient needed continuous low dose PPI which was significantly reduced when compared to pre-endoscopic intake. CONCLUSIONS: Endoluminal band ligation is a safe, well tolerated, cost-effective therapeutic option for refractory GERD. Conflict of Interest: None declared.

ESOPHAGUS: ENDOSCOPY: VARICEAL BLEEDING P534: EARLY MORTALITY AND REBLEEDING FOLLOWING ACUTE VARICEAL HAEMORRHAGE IN PATIENTS WITH LIVER CIRRHOSIS AND SCHISTOSOMAL PERIPORTAL FIBROSIS Sara Elfadil Abbas Mohammed Ali1, Abdelmonem Eltayeb Abdo2, Hatim Mohammed Yousif Mudawi1 1 Faculty of Medicine University of Khartoum, Internal Medicine, and 2National Center for Gastrointestinal and Liver Disease, Gastroenterology, Khartoum, Sudan

AIMS: To assess the rate and risk factors associated with rebleeding and mortality at 5 days and six weeks following acute variceal haemorrhage in patients with portal hypertension secondary to liver cirrhosis and Schistosomal periportal fibrosis. METHODS: A prospective study conducted during the period from March to December 2014. Patients with portal hypertension presenting with acute variceal haemorrhage secondary to liver cirrhosis (Group A) or Schistosomal periportal fibrosis (Group B) presenting within 24 h of the onset of the bleeding were included in the study and followed for a period of 6 weeks.

RESULTS: A total of 94 patients were included in the final analysis. Thirty two patients (34%) had liver cirrhosis (Group A) and 62 (66%) patients had periportal fibrosis (Group B). The 6 -week and 5 days mortality was 53% and 16% respectively in group A compared to 10% and 0% in group B (P value 0.000 and 0.004). In group A; CTP class C and rebleeding within 5 days were associated with 5 days mortality (P value 0.029 and 0.049


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 respectively) and CTP class C was a risk factor for 6- week mortality (P value 0.018). In group B; mortality was associated with rebleeding within the 6- week follow up period and blood transfusion (P value 0.005 and 0.049). The 6- week and 5 days rebleeding rate in group A were 56% and 25% respectively compared to 32% and 3% in group B (P value 0.015 and0.002). Clinical presentation with encephalopathy was a risk factor for 5 days rebleeding in group A (P value 0.005) while grade III periportal fibrosis and blood transfusion were risk factors for 6- week rebleeding in group B (P value 0.004 and 0.02)

CONCLUSIONS: The 6-week and 5 days mortality and re bleeding were significantly higher in patients with liver cirrhosis compared to patients with Schistosomal periportal fibrosis. Conflict of Interest: None declared.

P535: ARE JUNCTIONAL VARICES IN COMMUNICATION WITH OESOPHAGEAL VARICES? Mazen Naga, Serag Esmat, Ahmed Elbadri, Hussein Okasha, Yehia M Naga Faculty of Medicine, Cairo University, Internal Medicine, Cairo, Egypt

AIMS: Bleeding from gastric varices is a life threatening complication of portal hypertension. We studied the incidence of rebleeding of junctional varices. METHODS: This work included 166 patients with gastric varices among 443 Egyptian patients with variceal bleeding, 88 (53%) patients with junctional varices and 89 (53.6%) patients with fundal varices and 11 patients had both types of varices. All patients with fundal and junction varices were injected by cyanoacrylate and followed up for the recurrence of varices and the variceal rebleeding for a period of 6.5 1.2 months.

RESULTS: Thirty four out of 88 (38.6%) patients with junctional varices had rebleeding. Rebleeding occurred in 11 out of 89 (12.4%) patients with fundal varices. The total incidence of rebleeding of junctional varices was significantly higher than the incidence of rebleeding in fundal varices (P < 0.001). An important observation in our study that we found that varices that occur distal to gastroesophageal junction (classified as GOV1) are not in communication with oesophageal varices and this was proved in our work by the observation that in the post injection X ray films that histoacryl injection of the junctional varices (GOV1) below the Z line showed that the histoacryl didn’t go to the oesophageal varix while injection of the oesophageal varix above the Z line fills the whole column of the varix. Mccormack et al. found that the blood flow at the z line is bidirectional which indicate that GOV1 are not communicating with oesophageal varices which supports our observation


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frequently mistaken for gastric folds specially if they are not actively bleeding. Conflict of Interest: None declared.

P536V: SALVAGE TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC STENT-SHUNT (TIPSS) COMBINED WITH GASTRIC CORONARY VEIN EMBOLIZATION (GCVE) IN A PATIENT WITH REFRACTORY VARICEAL BLEEDING: A CASE REPORT Ke Meng, Gang Sun, Jiangtao Liu, Chuangye He, Bin Yan, Xiaomei Zhang, Liangliang Guo, Qing Feng, Le Tian Hainan Branch of PLA General Hospital, Gastroenterology and Hepatology, Sanya, China

AIMS: To reveal the role of salvage TIPSS combined with GCVE in a patient with variceal bleeding, refractory to initial medical and endoscopic therapy. METHODS: We describe a TIPSS combined with GCVE procedure in a 44-year-old male patient with life-threatening variceal bleeding in whom the conventional medical and endoscopic procedure had failed. The patient was admitted in our hospital because of intermittent melena for one month and hematemesis for two days. CT showed cirrhosis, esophageal varices and ascites. Although medical treatment and three endoscopic therapy procedures (including two emergency endoscopic therapies) were performed successively, a life-threatening rebleeding still occurred. TIPSS combined with GCVE was chosen as a salvage therapy.

RESULTS: The life-threatening rebleeding was controlled successfully and the patient survived the acute bleeding episode. After 6 months follow-up, the esophageal varices were stable and rebleeding didn’t occur. CONCLUSIONS: TIPSS combined with GCVE should be considered as salvage therapy when medical and endoscopic treatment is unsuccessful in patients with refractory variceal bleeding. Conflict of Interest: None declared.

CONCLUSIONS: Junctional varices has a significantly high rate of rebleeding as they may be easily missed during endoscopic examination as they are usually multiple and are


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P537: DECREASING UTILIZATION OF EMERGENT TRANSJUGULAR INTRAHEPATIC PORTOSYTEMIC SHUNTS (TIPS) IN PATIENTS HOSPITALIZED WITH ACUTE VARICEAL HEMORRHAGE (AVH): ANALYSIS OF NATIONWIDE HOSPITALIZATIONS FROM 2000– 2008 Nilay Kumar1, Vikram Kanagala2, Gagan Kumar3, Nanda Venu4 1 Aurora St.Luke’s Medical Center and UWSMPH Madison, Gastroenterology and Hepatology, Milwaukee, 2Medical College of Wisconsin, Milwaukee, 3Northeast Georgia Heath System, Atlanta, USA and 4Virginia Mason Medical Center, Seattle, USA


P538: OESOPHAGEAL PERFORATION - A LIFE THREATENING COMPLICATION OF BALLOON TAMPONADE WITH A SENGSTAKEN-BLAKEMORE TUBE FOR BLEEDING OESOPHAGEAL AND GASTRIC VARICES Brianna Twomey St Vincent’s Hospital, Melbourne, Australia

AIMS: The impact of continued advancement in endoscopic and pharmacological management of AVH and its impact on utilization of TIPS has not been studied.

AIMS: Balloon tamponade using a Sengstaken- Blakemore (SB) tube is an effective lifesaving option in the management of acute oesophageal and gastric variceal bleeding. The procedure is often used as a temporising measuring to achieve short term haemostasis by applying direct compression to varices until more definitive treatment can be instituted. However, the use of a Sengstaken-Blakemore tube has been associated with a number of complications including aspiration pneumonia, airway obstruction, and oesophageal erosion and perforation.

METHODS: National Inpatient Sample (NIS) database from

METHODS: We present a case of a patient who developed an

2000–2008, patients with primary discharge diagnosis of AVH undergoing TIPS were identified. The outcomes studied were mortality and length of stay. Multivariate logistic regression was performed, analysis was adjusted for age, sex, race and other relevant co-morbid conditions.

oesophageal perforation following the insertion of a Sengstaken-Blakemore tube.

RESULTS: We analyzed 338,714 patients hospitalized with AVH and 15,369 of them underwent emergent TIPS for refractory AVH. The all cause in-hospital mortality in AVH has decreased from 12.3% in 2000 to 10.9% in 2008 (P < 0.001). The rate of TIPS in patients with AVH has also shown a steady decline from 5.6% to 3.9% (P < 0.001). The length of hospital stay was 4.9 days (95% confidence interval (CI): 4.7–5.2 days) longer in patients undergoing TIPS. Higher mortality in AVH were associated with age (OR 1.02; 95%CI 1.01–1.03), male gender (OR 1.3; 95%CI 1.28–1.32), acute renal failure (OR 4.2; 95%CI 3.9–4.5), hepatic encephalopathy (OR 1.7 ; 95%CI 1.6–1.8), coagulopathy (OR 1.4; 95%CI 1.3–1.5), mechanical ventilation (OR 13.1; 95%CI 12.1–13.9) and vasopressor use (OR 3.25; 95%CI 2.2–4.9).

RESULTS: A 53 year-old male presented with haematemesis and melena on the background of Child-Pugh B cirrhosis secondary to hepatitis C virus. The patient was commenced on Octreotide and Pantoprazole infusions, and endoscopic band ligation of oesophageal varices was later performed. Following the procedure, the patient suffered ongoing haematemesis and was transferred to the intensive care unit for resuscitation and urgent intervention. Rapid endotracheal intubation was followed by a gastroscopy that revealed fresh blood in the stomach. A Sengstaken- Blakemore tube was inserted and the gastric balloon inflated following confirmation of tube position with auscultation. A subsequent chest radiograph revealed a round radiolucent area corresponding to the gastric balloon projecting over the right hemi-thorax. The gastric balloon was immediately deflated and removed. A full thickness oesophageal tear was further confirmed by a repeat gastroscopy and computed tomography imaging.

CONCLUSIONS: Our study indicates that there has been a

CONCLUSIONS: Whilst oesophageal perforation secondary to

significant decrease in the all cause in-hospital mortality related to AVH from 2000 to 2008. Similarly the utilization of TIPS for refractory AVH has shown a significant decrease. More widespread utilization of prophylactic medications (such as betablockers) and endoscopic variceal banding likely attributes to these findings. Also a better patient selection for undergoing TIPS could explain the decreasing mortality in this group. The need for mechanical ventilation or vasopresors and presence of acute kidney injury, coagulopathy or hepatic encephalopathy were strongly associated with increased mortality in AVH. Conflict of Interest: None declared.

Sengstaken- Blakemore tube misplacement is a relatively rare complication, it carries a high incidence of associated mortality. This case illustrates that auscultation alone is not an adequate method to confirm Sengstaken-Blakemore tube placement. We recommend the use of routine chest radiography or ultrasonography before and after balloon inflation. Endoscopic guided insertion is another method that can be utilised to ensure correct balloon positioning. Conflict of Interest: None declared.



P539V: CAP ASSISTED GLUE INJECTION OF SPURTING ESOPHAGEAL VARICES: NEW MODALITY OF THERAPY Shrihari Anikhindi, Vikas Singla, Ashish Kumar, Praveen Sharma, Naresh Bansal, Anil Arora Sir Ganga Ram Hospital, Institute of Liver, Gastroenterology and Pancreaticobiliary Sciences, New Delhi, India

AIMS: Active spurting from esophageal varices (EV) in advanced cirrhotics is a predictor of failure of conventional endotherapy with endoscopic variceal ligation (EVL) or sclerotherapy (EST). Transjugular Intrahepatic Portosystemic Shunt (TIPS) is proposed as first line therapy in these patients. Injection of spurting varix with cyanoacrylate glue is not well studied. Direct injection of EV at site of spurt is difficult due to respiratory movements. Distal cap attachment helps in stablishing endoscope and injection of glue at bleeding point. We evaluated efficacy of cap assisted glue injection (CAGI) in achieving hemostasis and prevention of early rebleed in spurting EV. METHODS: Consecutive patients with Child B/C cirrhosis, and active EV spurt during endoscopy underwent CAGI. Point of spurt was focused in field of vision and 1–2 mL cyanoacrylate glue was injected at bleeding site. In case of failure, alternate modality was used. EVL was performed for remaining varices in same session or next day.

RESULTS: 170 patients with active EV bleed underwent endotherapy in 2 years (May 2014-May 2016). Twenty five patients (80% Males) had spurting EV, and underwent CAGI. Eleven pts (44%) had Child C cirrhosis (median CTP score = 9). Fourteen patients had index bleed, 11 patients had more than 1 previous bleed, and were on secondary prophylaxis. Immediate hemostasis was achieved in all patients; 23 patients required 1 while 2 patients required 2 injections. No procedure related complications were seen. Five day rebleed was seen in 2 patients. One underwent rescue TIPS, other underwent Danis SX-ELLA stent placement as he had encephalopathy precluding TIPS. This was the only patient who had mortality due to septic shock. All other patients were successfully discharged. CONCLUSIONS: CAGI is a safe, easy and effective modality for prevention of early rebleed in patients with spurting esophageal varix in advanced cirrhosis. Conflict of Interest: None declared.


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PEDIATRIC ENDOSCOPY: ENDOSCOPY: PEDIATRIC P540: REMOVAL OF FOREIGN BODIES FROM GASTROINTESTINAL TRACT IN CHILDREN. HOW TO CHOOSE AN EFFECTIVE ENDOSCOPIC TOOL? Stanislaw Pieczarkowski1, Kwinta Przemko2, Kinga KowalskaDuplaga1, Malgorzata Sladek1, Zofia Grzenda-Adamek1, Robert Wilk3, Bartosz Bogusz3, Krzysztof Fyderek1 1

Jagiellonian University Faculty of Medicine, Department of Pediatrics, Gastroenterology and Nutrition, 2Jagiellonian University Faculty of Medicine, Department of Pediatrics, and 3Jagiellonian University Faculty of Medicine, Department of Pediatrics Surgery, Krakow, Poland

AIMS: Assessment of effectiveness of foreign bodies (FB) removal with the first tool used and factors that determine the success or failure. METHODS: We anlysed gastroscopies (years2012–2014) where the indication was swallowed FB. FBs were found in 59 children, including 28 boys, 31 girls, aged from 0.5 to 14 years, (median age 3 years).

PATIENTS WERE DIVIDED IN TWO GROUPS: : Group I. (45 patients)- removal of FB with the first tool was effective, and Group II. (14 patients) - it was not effective. Both groups were analyzed with respect to FB: location, type and used tool.

RESULTS: The most frequently removed FB were coins (n = 32 ; 27 in group I. and 5 in group II), button-batteries (n = 9, 6 in group I. and 3 in group II.) and other FBs. (n = 18, 12 in group I. and 6 in group II.). No statistically significant differences between the study groups were found with respect to age of children, sex, time of FB ingestion, or the endoscopist. In group I. the effectiveness of the first tool used was 84.4% for coins and 66.7% for button-batteries and other FBs. Rat-tooth was found to be effective tool for coins- but not for buttombatteries. In the case of other FB, rat tooth were not very effective, removed them, only in 60% of cases, when another tool was used still effectiveness was not high and amounted to 75%. CONCLUSIONS: Using an inappropriate retrieval tool is associated with longer duration of endoscopy. For coins the most effective tool is rat-tooth while in the case of button batteries and other FB- types, - Roth net or and grasper basket are more useful. Other FB can be difficult to remove, and the problems are associated with the FB itself. It is easier to remove FB from the esophagus than from the stomach or duodenum. Conflict of Interest: None declared.


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P541V: MANAGEMENT OF ACHALASIA WITH GASTRIC ANTRAL STRICTURE FOR A PEDIATRIC PATIENT USING ENDOSCOPIC TECHNIQUE Jiaxin Xu1, Pinghong Zhou1, Ying Fang2 1

Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China and 2 Xi’an Children’s Hospital, Department of Gastroenterology, Xi’an, China

AIMS: Not applicable. METHODS: Not applicable. RESULTS: Not applicable. CONCLUSIONS: A 13-year-old boy, with a history of interrupted vomiting for three years, was diagnosed with achalasia by esophagogastroduodenoscopy, barium meal, and manometry. In addition, he burst out fulminant myocarditis, severe septicopyemia and multiple organ dysfunction syndrome a year ago, when a circumferential ulcer was occurred in gastric antral which turned to be stricture caused by severe fibrosis after. Peroral endoscopic myotomy (POEM) procedure were as follows. Submucosal injection and an initial mucosal incision was made in the 6 o’clock position on the posterior esophagus about 4 cm above the esophagogastric junction (EGJ). Then a submucosal tunnel was created, passing over the EGJ. The myotomy was begun at approximately 1 cm distal to the mucosal entry point, performed passing over the EGJ to about 2 cm in the proximal stomach. After careful hemostasis, the mucosal incision site was closed with 7 metal clips. The tonus of lower esophageal sphincter (LES) reduced substantially after POEM. Then the stricture of gastric antral was incised radially with a hook knife. After two months, the objective sign of reflux esophagitis and the condition of gastric antral stricture were observed by EGD. Conflict of Interest: None declared.

P542: USE OF LARYNGEAL MASK AIRWAY DURING ANAESTHESIA FOR ENDOSCOPIC PROCEDURES IN CHILDREN Vinod Kolimarala, Wayne Hosein, Sally Renwick, Marilyn Bartimeus, Hany Banoub, Mashhood Ayaz, Sonny Chong Epsom & St Helier University Hospital NHS Trust, Paediatric Gastroenterology, Carshalton, UK

AIMS: Retrospective evaluation regarding the safety and efficacy of general anaesthesia with Sevoflurane and Propofol using Laryngeal mask airway (LMA) in endoscopic procedures over a 6 year period in a children´s unit. METHODS: Children under 16 years of age who underwent upper GI endoscopy (OGD) +/- insertion of pH/impedance probe +/- colonoscopy in a day surgery theatre in a children´s unit were included in the study. Procedure: The procedure was

Digestive Endoscopy 2017; 29(Suppl 1): 29–261 conducted by a paediatric anaesthetist, with spontaneous respiration, sevoflurane/isoflurane and Propofol. The average dose of Propofol used was 2–4 mg/kg at induction. The average concentration of sevoflurane was 2–3% (MAC 1–1.5) Time required for induction of anaesthesia, anaesthesia, endoscopy, recovery, and complications during the procedure were recorded. Vital signs including heart rate, respiratory rate blood pressure and pulse oximetry were measured at baseline and every 5 min until patient recovery. In cases requiring a pH/ impedance probe insertion this was done successfully with the LMA in place and position was checked by endoscopy. In case of difficulty the LMA was deflated slightly to allow passage of endoscope and following insertion.

RESULTS: 380 patients were included over 6 year period from 2010–2015. The age range was from 3 years to 16 years with a median age of 8 years. None of the patients required intubation for complications of the procedures or inability to maintain airway. There were no haemodynamic complications. Three patients complained of sore throat required medical review and one patient required an inpatient admission for aspiration pneumonia which resolved spontaneously. CONCLUSIONS: In our study, we were able to demonstrate that the use of an LMA does not restrict or complicate the procedure of upper GI endoscopy. In addition it is shown to be a safe way of administering inhalational agents in children with a short recovery time. Impedance/pH probe can be inserted safely along with an endoscope. Conflict of Interest: None declared.

P543V: PERORAL ENDOSCOPIC MYOTOMY IN CHILDREN WITH IMPAIRED PULMONARY FUNCTION Valerio Balassone, Tamara Caldaro, Simona Faraci, Laura Del Prete, Francesca Rea, Anna Chiara Contini, Filippo Torroni, Erminia Francesca Romeo, Renato Tambucci, Giulia Angelino, Giovanni Federici di Abriola, Paola De Angelis, Luigi Dall’Oglio Bambino Gesu Children Hospital I.R.C.S.S., Digestive Surgery and Endoscopy Complex Unit, Rome, Italy

AIMS: Peroral Endoscopic Myotomy (POEM) has recently established as a safe and effective treatment for achalasia and other esophageal spastic disorders in adults. Despite preliminary results are encouraging, the experience in children with comorbidities is limited. We aimed to report our experience in a girl with sigmoid esophagus and impaired pulmonary function. METHODS: A 13 year girl was referred to our center for dysphagia, regurgitation, nocturnal cough and recurrent aspiration (Eckardt score = 7). Despite a good nutritional status, the pulmonary function was reduced by chronic aspiration and the previous history of chest radiation for Hodgkin´s Lymphoma.


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 The barium swallow showed a sygmoid shape esophagus and the high resolution manometry confirmed a Type I achalasia with absence of peristalsis in 100% of liquid swallows. To avoid prolonged intubation and according to the achalasia characteristics, a standard-lenght myotomy was scheduled.

RESULTS: POEM was carried out in our center under general anesthesia. A11 cm long myotomy with a posterior tunnel was performed and the procedure duration was 72´. The mucosal entry was closed with 5 standard clips. The day after endoscopy and esophagram confirmed the integrity of esophageal mucosa and the patient was progressively re-feeded. The clinical course was uneventful and the patient was discharged after 3 days. At the 3-months follow up Eckardt score was 1 and no regurgitation or night cough were referred. CONCLUSIONS: POEM is a valid option to be taken into account in children to avoid prolonged intubation in children with comorbidities. Conflict of Interest: None declared.

P544: NOVEL COADJUVANT TREATMENTS FOR REFRACTORY ESOPHAGEAL STRICTURES IN CHILDREN Simona Faraci, Valerio Balassone, Erminia Francesca Romeo, Francesca Rea, Anna Chiara Contini, Tamara Caldaro, Filippo Torroni, Giulia Angelino, Renato Tambucci, Giovanni Federici di Abriola, Paola De Angelis, Luigi Dall’Oglio Bambino Gesu Children Hospital I.R.C.S.S., Digestive Surgery and Endoscopy Complex Unit, Rome, Italy

AIMS: Mitomycin C is an antineoplastic and antiproliferative agent. Dexamethasone has anti-inflammatory action. The role of these drugs as coadiuvant of refractory esophageal stricture (RES) is not standardized. This study evaluated the efficacy of combined dexamethasone and Mitomycin injection (DMI) as a coadjuvant in the treatment of RES.

METHODS: From 2013 to 2016, children with RES treated with DMI were retrospectively analyzed. Age, type of stenosis, dysphagia score (DS), treatments like endoscopic dilations, stent placement or surgery were recorded. All patients underwent one or more sessions of combined treatment (in a 2– 4 weeks interval), consisting in esophageal dilations with Savary-Gilliard followed by mitomycin C (0.1 mg/dL in 5 min) directly injected at the dilated stricture and systemic dexamethasone (0.5 mg/kg bid for 3 days). All patients received proton pump inhibitors. Efficacy was measured as DS (0 no dysphagia–4 severe dysphagia) and number of further dilations requirement.


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DMI, 50% of patients improved the DS (from 4 to 1). No further dilations were needed in 2 patients. Three patients required furhter dilatations (mean 7; range 4–11). In 4 patients the DS was not improved: 1 underwent surgery, 3 patients were managed conservatively with the placement of a second esophageal Dynamic Stent® or intraesophageal balloon.

CONCLUSIONS: In our experience, combined treatment of topical mitomycin C and systemic dexamethasone showed a promising role as coadjuvant of esophageal strictures improving dysphagia score and delaying the need of surgery. Conflict of Interest: None declared.

P545: ENDOSCOPIC ULTRASOUND-GUIDED DRAINAGE OF PANCREATIC FLUID COLLECTIONS IN CHILDREN WITH FULLY COVERED SELF-EXPANDING METAL STENTS WITH MEDIUM TERM FOLLOW UP Zaheer Nabi, Mohan Ramchandani, Sundeep Lakhtakia, Jahangeer Basha, Rajesh Gupta, D. Nageshwar Reddy Asian Institute of Gastroenterology, Hyderabad, India

AIMS: Endoscopic ultrasound (EUS) guided drainage with fully covered self expanding metallic stents (FCSEMS) have been successfully used in adult patients. However, the utility of FCSEMS in children with PFCs is unknown. The aim of present study was to evaluate the feasibility, safety and efficacy of EUSdrainage of PFCs using FCSEMS in children. METHODS: We retrospectively evaluated the data of children (≤18 years) who underwent EUS-drainage of walled off necrosis (WON) using FCSEMS at our institution. All FCSEMS were removed between 1–3 months. Feasibility, safety and efficacy were analysed.

RESULTS: Twenty one children (20 boys, mean age 14.9 2.34 years, range 9–18 years) underwent EUS guided drainage of WON with FCSEMS. The median size of WON was 90 mm (55–148 mm). The median interval between onset of acute pancreatitis and EUS guided drainage was 58 days (range 30–288 days). The technical and clinical success rates were 1000% and 95% respectively. There were no major complications. After a median follow up of 360 days (range: 30–1020), there was one recurrence of WON. CONCLUSIONS: EUS- drainage of WON using FCSEMS is safe and efficacious in children. The utility of FCSEMS in children should be further explored and compared with plastic stents. Conflict of Interest: None declared.

RESULTS: 10 children (median age 4.5 years, range 13 month–10 years) with RES (5 anastomotic, 5 caustic stricture) were included. Mean follow-up was 1.7 years (range 4 months–3.3 years). Before DMI, all patients required a mean of 5 dilations (range 1–10). Dynamic Stent® was also placed in 3 patients. One patient was lost to follow up. After


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P546: ENDOSCOPIC ULTRASOUND GUIDED DRAINAGE OF PANCREATIC FLUID COLLECTIONS IN CHILDREN


Zaheer Nabi, Sundeep Lakhtakia, Jahangeer Basha, Rajesh Gupta, Radhika Chavan, Mohan Ramchandani, D. Nageshwar Reddy

absence of esophageal peristalsis. AC is rare in children with unclear optimum management strategies. Per oral endoscopic myotomy (POEM) is a novel technique for management of achalasia with encouraging results in adult patients. The efficacy and safety of POEM is not known for pediatric AC. The aim of our study was to evaluate the safety and efficacy of POEM in children with achalasia cardia.


METHODS: The data of all children (50%) and complete resolution of symptoms at 1 year follow up. Median weight gain of children at 1 year was 1.65 kg (range, 0.0–4.6). CONCLUSIONS: POEM is safe and effective for children with achalasia cardia. Conflict of Interest: None declared.

P548: ERCP IN THE MANAGEMENT OF PANCREATICOBILIARY DISORDERS IN CHILDREN – AN EXPERT PERSPECTIVE FROM EAST Amol S Dahale, Ajay Kumar, Sanjeev Sachdeva, Siddhartha Srivastav, Pritul D. Saxena, Amarender S. Puri GB Pant Institute of Postgraduate Medical Education and Research, Gastroenterology, New Delhi, India

AIMS: To analyze spectrum and assess safety, efficacy and outcome of Pediatric ERCP. METHODS: We analyzed ERCP records from G B Pant Institute of postgraduate education and research (GIPMER) since January 2011 to June 2015. All patients between age group 0–15 years included in analysis.

RESULTS: Total 164 ERCP carried out at GIPMER on 126 pediatric patients. Out of 164, 38 were repeat procedures. Of 126, 67 were male (53.2%) and 51 were female (46.8%). Most common indications for ERCP were CBD stone [n–50 (30%)] followed by chronic calcific pancreatitis [n 38 (23.0%)]. PD injury with leak constituted n–21 (13%), while CBD Injury with leak comprised n–12 patients (7.0%). Other less common indications were biliary ascariasis (n–7, 4.0%), choledochal cyst


Digestive Endoscopy 2017; 29(Suppl 1): 29–261 (n–15, 9%), cystolithiasis (n–6, 3.8%). The Cannulation success achieved in 89% (n–146 ); while procedural success achieved in 86% (n–141). Complications occurred in 8 patients (5%) [2pancreatitis, 2 -retroperitoneal perforation, 2-post prodecural bleed, 2- hypoxia]. All complications were managed conservatively with no procedure related mortality.

CONCLUSIONS: Pediatric ERCPs are safe and complications rates comparable to adults. Indications are more varied than adult population. In era of less invasive therapeutics ERCP further highlights its importance in Pancreaticobiliary therapeutics. Conflict of Interest: None declared.

P549: CORRELATION OF CLINICAL, SEROLOGICAL AND HISTOPATHOLOGICAL FINDINGS IN PAKISTANI CHILDREN WITH CELIAC DISEASE Brekhna Aurangzeb1, Yasir bin Nisar2, Nadeem Akhtar1, Mudassar Gondal1 1 Pakistan Institute of Medical Sciences, Children Hospital, and 2UNOPS, Global Fund, Islamabad, Pakistan

AIMS: The aim of the study was to investigate the correlation of histopathological findings of intestinal mucosa with clinical presentation in children with celiac disease. METHODS: A cross sectional study comprising of 73 children


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clinical features, nutritional status, serological, endoscopic, histopathological findings and Marsh staging of all the enrolled children were recorded. Data was analyzed using SPSS software and correlation between modified Marsh staging and clinical features was examined by using Pearson correlation.

RESULTS: The mean (SD) age of all children with celiac disease was 6.1 (2.7) years at the time of presentation and 40 (55%) were boys. The mean (SD) duration of symptoms was 2.28 (2.6) years, ranged from 1 month to 8 years. GI symptoms (diarrhea/ constipations/vomiting/abdominal pain etc) were present in 41 (56%), 17 (23%) reported failure to thrive, and 3 (4%) had bone pains. Nutritional status showed that 33 (45%) had stunting and 55 (75%) were underweight and 42 (58%) had anemia at the time of presentation. Histopathological examination revealed that 53 (73%) had modified Marsh stage 3a, 12 (16%) had Stage 3b and 8 (11%) had stage 3c. The mean (SD) TTG IgG was 350 Iu/mL. The modified Marsh staging was not associated with duration of symptoms (P > 0.05) and GI symptoms (P > 0.05). However there was significant association between Anti-tTG levels, mean baseline hemoglobin, and severity of mucosal damage (P < 0.001 for all). CONCLUSIONS: Coeliac disease in children should be thoroughly investigated with both histopathology and serology according to the standard guidelines to aid in proper management of the disease. This is especially important for implication in developing countries like Pakistan because of economic reasons. Conflict of Interest: None declared.

was conducted at the Children’s Hospital, Pakistan Institute of Medical Sciences, Islamabad from July 2012 to May 2016. The
