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DIFFERENT SEGMENTAL TRANSIT TIME (TT) THROUGH THE SMALL BOWEL MAY AFFECT WIRELESS CAPSULE (WC) ENDOSCOPY
S156
Abstracts / Digestive and Liver Disease 41S (2009), S1–S167
in 18,6% of cases in day hospital regimen and in 8.6% of cases in outpatients. Conclusions: Our data show that in Lombardia, over the last 6 years, the diffusion of VCE increased steadily. This large retrospective series of patients confirms that, the indications, diagnostic yield and safety profile of VCE in everyday clinical practice closely match those reported in published studies. # Q. Diagnostic endoscopy 6. Video-capsule
P.218 OBSCURE GASTROINTESTINAL BLEEDING: THE SINGLECENTER EXPERIENCE OF A CONSECUTIVE SERIES OF PATIENTS UNDERGOING CAPSULE ENDOSCOPY E. Dabizzi ∗ , S. Messeri, A. Santini, E. Surrenti, G. Macrì, C. Surrenti Azienda Ospedaliero Universitaria Careggi, Firenze Background and aim: Obscure gastrointestinal bleeding (OGIB) is defined as recurrent or persistent bleeding or iron deficiency anemia after negative initial evaluation exams. Various issues contribute to make it an expensive cost in every National Health Service, like a long median time to get a diagnosis and a high number of requested reimbursement for hospitalization and comorbid conditions. Capsule endoscopy (CE) is a novel diagnostic tool in the investigation of small bowel (SB) diseases, allowing an entire SB mucosa visualization. It has been shown to be superior to other diagnostic techniques in the evaluation of OGIB. Aim: To assess the diagnostic yield of CE in a consecutive series of patients with OGIB, considering the bleeding different causes, the clinical presentation and the timing of CE. Material and methods: Between January 2004 and August 2008, 129 CE studies were performed at our institution for the indication of OGIB. Data on the 129 pts were obtained by retrospective review of an internal database of pts. Previous the CE investigation, all pts underwent initial examination with upper and lower GI endoscopy, without finding any source of bleeding. They were retrospectively divided in two groups: the obscure-occult group and the obscure-overt group. We used χ2 test for statistical analysis. Results: The diagnostic yield of CE, defined as the identification of a clinically significant lesions thought to be the source of OGIB, was 60% in the obscure-occult group and 70% the obscure-overt group without statistically significant differences between the groups.SB angioectasias were the most common clinically significant findings (39,5%), followed by ulcers (22,9%) and mucosal erosions (22,9%). Considering the obscure-overt group, the timing of CE and the quality of bowel preparation was not associated with increased diagnostic yield. Visualization of the entire SB was achieved in 80,6%. No complications occurred. Conclusions: CE is an important tool in the evaluation of OGIB after previous initial evaluation exams. Although the diagnostic yield varies between 60-70%, the diagnostic advantage is 100% in patients with clinically significant findings, since the source of bleeding was not recognized by previous diagnostic procedures. However, to improve the CE diagnostic capabilities, more studies are needed to better define the clinical profile of the “ideal candidate” for CE. # Q. Diagnostic endoscopy 6. Video-capsule
P.219 PREPARATIONS FOR PILLCAM COLON CAPSULE ENDOSCOPY ARE AS ACCEPTABLE AND SAFE AS THAT FOR STANDARD COLONOSCOPY C. Spada ∗ , M.E. Riccioni, L. Petruzziello, P. Cesaro, G. Costamagna Catholic University, Digestive Endoscopy Unit, Roma Background and aim: PillCam Colon Capsule Endoscopy (PCCE) is
an emerging non-invasive method to explore the colon. The preparation (prep) for PCCE lasts longer than that for standard colonoscopy (SC) and requires additional laxatives as it should clean the colon and also facilitate the progression of the capsule. Concerns arise because the large volume of liquids required for PPCE prep may decrease the compliance to the procedure. Aim of this study was to compare the satisfaction between patients (pts) who received 2 different PCCE regimens with those who received SC regimen. Adverse events occurrence was also compared. Material and methods: 40 pts prospectively enrolled in the validation phase of an Italian Multicenter Clinical Trial that evaluates the effect of PCCE prep and procedure on colon cleansing level were compared with a similar group who received prep for SC. Pts were randomized to 2 different PCCE regimens. Regimen I (baseline regimen) included clear liquid diet and 3 liters (L) of PEG on day -1, and 1L PEG in the morning of the procedure day. Additional small doses of NaP boosters were given following capsule ingestion to maintain clean colon and enhance capsule propulsion. Regimen II included low residue diet on days -5 to -2, 4 senna tablets on day -2, clear liquid diet and 3L of PEG on day -1, and PEG instead of NaP boosters on the procedure day. Pts were asked to grade the prep as easy, acceptable, unpleasant, intolerable. They also indicated if they had nausea, vomiting, abdominal pain, headache and vertigo. Pts who received prep for PCCE were compared between the 2 groups and with the group who received prep for SC (low residue diet on days -5 to -1, 4 senna tablets on day -2, 4L of PEG on day -1). Results: No statistical differences were found in term of satisfaction between PCCE regimen I and II, and the SC regimen (Table 1). In addition, no differences were found for adverse events occurrence. Table 1 Prep satisfaction
Easy Acceptable Unpleasant Intolerable
PCCE Regimen I (n=20)
PCCE Regimen II (n=20)
p
PCCE Regimens (n=40)
SC Regimen (n=40)
p
4 11 5 0
4 9 6 1
NS NS NS NS
8 20 11 1
14 14 8 4
NS NS NS NS
Conclusions: PCCE regimens appear as acceptable and as safe as SC regimen. Furthermore, PCCE regimen I (baseline) and regimen II show similar patient’s satisfaction and safety. # Q. Diagnostic endoscopy 6. Video-capsule
P.220 DIFFERENT SEGMENTAL TRANSIT TIME (TT) THROUGH THE SMALL BOWEL MAY AFFECT WIRELESS CAPSULE (WC) ENDOSCOPY N. Pallotta ∗ ,1 , F. Gionata 1 , E. Romeo 2 , M. Cesarini 1 , P. Vernia 1 , S. Cucchiara 2 , E. Corazziari 1 1
Dipartimento di Scienze Cliniche Università Sapienza, Roma; Gastroenterologia ed Epatologia Pediatrica Università Sapienza, Roma 2
Background and aim: Wireless capsule endoscopy (WCE) of the small bowel (SB) cannot be completed in ∼25% of the studies. At WC pyloric and ileo-colonic junction (ICJ) landmarks enable to assess the transit time through the stomach and the SB. However is not known the SB segmental transit times of the WC and whether they might affect the SB WC assessment. After the distension of GI lumen with macrogol solution, ultrasound (US) can assess wall contractions, intraluminal flow, and visualize WC as hyperechoic particle. To assess segmental TT of the WC through the duodenum, the 1st jejunal loop, jejunum, proximal, middle-distal, and terminal ileum. Material and methods: Nine pts (4 F, age 12-70 yrs) with the suspect of SB pathology were assessed. After a 12 hrs fasting period and standard preparation, pts ingested a WC and were submitted to small intestine
Abstracts / Digestive and Liver Disease 41S (2009), S1–S167 contrast ultrasonography (SICUS) after the ingestion of 375-500 ml of macrogol solution (1). With continuous US scanning the transit of the WC was followed through the stomach and the SB until the ICJ and the colon, recorded and later reviewed. Results: At WC the TTthrough the stomach and from the terminal ileum to the colon was 57±47min and 57.5±68min, respectively. At SICUS WC transit through the stomach was 57±47min; through the duodenum, the 1st jejunal loop and jejunum was 4±2min, 7±3min, and 15±14min, respectively, The transit of the WC through the proximal, middle-distal and terminal ileum was 47±34min, 37±22min, and 40±27min, respectively. The passage of the WC through the ICJ into the colon occurred after 71±62min. The slow transit through the ileum and ICJ was due to 1) non propulsive segmenting intestinal contractions causing frequent stops of WC, 2) backward displacement of the WC related to contractions causing ileo-ileal and colon-ileal refluxes (# 13±9.5, range 1-31). A correlation was found between the number of refluxes and time to pass the ICJ (r=0.79, p<0.02). Conclusions: Because of the slow transit of the WC at the level of the ileum and ICJ the WC battery life can end before the WC reaches the colon. The rapid duodenal-jejunal transit of the WC may limit an appropriate assessment of mucosal lesions at this level. The markedly different motor activity of the duodenum, jejunum, ileum and ileo-colonic junction may differently affect a proper and complete WC assessment of the small bowel. 1)Pallotta et al, Lancet 1999 # Q. Diagnostic endoscopy 6. Video-capsule
P.221 FIVE HUNDRED EARLY URGENT ENDOSCOPIES FOR SUSPECTED UPPER GI BLEEDING: ALWAYS NEEDED? ALWAYS EFFECTIVE? T. Togliani ∗ , S. Pilati, N. Mantovani, A. Savioli, C. Pulica, V. Benedini Az. Osp. Carlo Poma, Mantova Background and aim: Upper gastrointestinal bleeding (UGIB) is a severe condition that can be treated endoscopically with success; costeffectiveness of early urgent endoscopy mainly depends on the correct selection of patients. Aim of this single center prospective study was to monitor the appropriateness of early urgent endoscopies for suspected UGIB in terms of patients selection and early outcomes. Material and methods: Five hundred consecutive patients with a first episode of suspected UGIB were included during a period of 29 months. An UGIB was suspected if haematemesis, coffee ground vomit or melaena could be demonstrated. All the patients underwent anamnesis, blood cell count, routine biochemistry and upper GI endoscopy within 6 hours from presentation. According to endoscopic results patients were divided in 4 groups: 1) active bleeding, 2) high risk lesions (white nipples on varices; Forrest IIa-IIb ulcers; Mallory-Weiss tears or Dieulafoy lesions or hemangiomas with an adherent clot), 3) low risk lesions, 4) no lesions; endoscopic therapy was performed in patients included in groups 1 and 2. We compared anamnestic and clinical pre-exam data to endoscopic results, for determining which signs or symptoms could predict the real need of an urgent endoscopic treatment. Statistical validation was evaluated by a χ2 goodness of fit test. Results: Among the 500 patients included 118 (24%) had active bleeding, 70 (14%) had high risk lesions, 187 (37%) had low risk lesions, 125 (25%) had no lesions. The presence of at least 3 characteristics among male sex, haematemesis, anemia, haemodynamic instability or liver cirrhosis predicted the belonging to group 1 or 2, and thus the need of an urgent endoscopic therapy, with an accuracy of only 71% (p<0.05); age, coffee ground vomit, melaena, use of NSAIDs/antiplatelet/anticoagulants or previous upper GI surgery did not show any statistical difference in the 4 groups of patients. Endoscopic treatment obtained an immediate haemostasis in 91% of cases; 4-week relapse rate and bleeding-related mortality rate were 7% and 1% respectively.
S157
Conclusions: Clinical parameters overestimated the bleeding risk and more than half of patients underwent unnecessary early urgent exams; thus an early endoscopic strategy seems adequate only if a very restrictive selection of patients is applied. When actual UGIB is present urgent endoscopic treatment is effective, safe and lasting. # R. Therapeutic endoscopy 1. GI bleeding
P.222 TREATMENT OF MALIGNANT GASTRO-DUODENAL OBSTRUCTION USING A NITINOL SELF EXPANDING METAL STENT (WALLFLEX™) – RESULTS OF A SINGLE CENTER FROM AN INTERNATIONAL PROSPECTIVE REGISTRY G. Costamagna, A. Tringali ∗ , M. Mutignani, P. Familiari, V. Perri Digestive Endoscopy Unit - Catholic University, Roma Background and aim: To document technical and clinical success, and complications associated with use of the WallFlex™ Duodenal Stent (Boston Scientific Corp, Natick, USA) for the palliative management of malignant gastro-duodenal obstruction in a large international multicentric experience. Results of the Italian experience from a single center participating to an international registry are reported. Material and methods: A web-based prospective registry is conducted at 12 endoscopy centers in 10 countries. Follow-up to 9 months is ongoing. An interim analysis of patients enrolled at the Digestive Endoscopy Unit – Catholic University of Rome, is reported. Results: 64/208 patients (mean age 73 years, 36 male) were enrolled at the Catholic University of Rome. Most common causes of the stricture were pancreatic cancer (50%), gastric cancer (14%), lymphnodal metastases (14%), duodenal cancer (9%), cholangiocarcinoma (8%) and gallbladder cancer (5%). Stent length was 6 cm (65%), 9 cm (32%), or 12 cm (3%). Technical success was achieved in 100% (64/64). Gastric Outlet Obstruction (GOO) improved from 3% of patients at Baseline tolerating soft solids or low residue/normal diet to 88% at 15 days, 88% at 30 days, 92% at 90 days, and 89% at 180 days. At 90 days post stent placement compared to Baseline, symptoms of post-prandial epigastric tenderness, nausea and vomiting improved in 71%, 75% and 87% of patients respectively and did not worsen in 100% for all three symptoms. One patient (1.6%) had abdominal pain after stent insertion treated by NSAID and then resolved. No other complication during the first week after duodenal WallflexTM insertion were recorded. GOO recurrence during follow-up was due to tumor ingrowth (14%), gastric paresis (6.3%) and tumor ingrowth+overgrowth (4.7%). Retreatment occurred in 9 patients (12.5%) and all received another self-expanding metal stent. To date 84.4% patients died, none due to stent or stenting related complications. Mean survival (to the last available follow-up or death) was 93 days. Conclusions: Preliminary results from a center of this International Registry related to the WallFlex™ Duodenal Stent, confirm the effectiveness of the endoscopic treatment of GOO with SEMS with acceptable complication profile. Endoscopic re-treatment of malfunctioning (ingrowth/overgrowth) or migrated SEMS is possible. # R. Therapeutic endoscopy 2. Stenosis palliation
P.223 TRANSNASAL VERSUS ORAL PEG PLACEMENT IN UNSELECTED PATIENTS: A PROSPECTIVE RANDOMIZED CLINICAL TRIAL I. Stroppa ∗ , R. Lionetti, A. Cocco, F. Andrei, M. Erboso, F. Pallone Policlinico Tor Vergata, Roma Background and aim: Conventional transoral PEG (O-PEG) is not always possible to perform due to neurological or oro-pharyngeal dis-
Abstracts / Digestive and Liver Disease 41S (2009), S1–S167
in 18,6% of cases in day hospital regimen and in 8.6% of cases in outpatients. Conclusions: Our data show that in Lombardia, over the last 6 years, the diffusion of VCE increased steadily. This large retrospective series of patients confirms that, the indications, diagnostic yield and safety profile of VCE in everyday clinical practice closely match those reported in published studies. # Q. Diagnostic endoscopy 6. Video-capsule
P.218 OBSCURE GASTROINTESTINAL BLEEDING: THE SINGLECENTER EXPERIENCE OF A CONSECUTIVE SERIES OF PATIENTS UNDERGOING CAPSULE ENDOSCOPY E. Dabizzi ∗ , S. Messeri, A. Santini, E. Surrenti, G. Macrì, C. Surrenti Azienda Ospedaliero Universitaria Careggi, Firenze Background and aim: Obscure gastrointestinal bleeding (OGIB) is defined as recurrent or persistent bleeding or iron deficiency anemia after negative initial evaluation exams. Various issues contribute to make it an expensive cost in every National Health Service, like a long median time to get a diagnosis and a high number of requested reimbursement for hospitalization and comorbid conditions. Capsule endoscopy (CE) is a novel diagnostic tool in the investigation of small bowel (SB) diseases, allowing an entire SB mucosa visualization. It has been shown to be superior to other diagnostic techniques in the evaluation of OGIB. Aim: To assess the diagnostic yield of CE in a consecutive series of patients with OGIB, considering the bleeding different causes, the clinical presentation and the timing of CE. Material and methods: Between January 2004 and August 2008, 129 CE studies were performed at our institution for the indication of OGIB. Data on the 129 pts were obtained by retrospective review of an internal database of pts. Previous the CE investigation, all pts underwent initial examination with upper and lower GI endoscopy, without finding any source of bleeding. They were retrospectively divided in two groups: the obscure-occult group and the obscure-overt group. We used χ2 test for statistical analysis. Results: The diagnostic yield of CE, defined as the identification of a clinically significant lesions thought to be the source of OGIB, was 60% in the obscure-occult group and 70% the obscure-overt group without statistically significant differences between the groups.SB angioectasias were the most common clinically significant findings (39,5%), followed by ulcers (22,9%) and mucosal erosions (22,9%). Considering the obscure-overt group, the timing of CE and the quality of bowel preparation was not associated with increased diagnostic yield. Visualization of the entire SB was achieved in 80,6%. No complications occurred. Conclusions: CE is an important tool in the evaluation of OGIB after previous initial evaluation exams. Although the diagnostic yield varies between 60-70%, the diagnostic advantage is 100% in patients with clinically significant findings, since the source of bleeding was not recognized by previous diagnostic procedures. However, to improve the CE diagnostic capabilities, more studies are needed to better define the clinical profile of the “ideal candidate” for CE. # Q. Diagnostic endoscopy 6. Video-capsule
P.219 PREPARATIONS FOR PILLCAM COLON CAPSULE ENDOSCOPY ARE AS ACCEPTABLE AND SAFE AS THAT FOR STANDARD COLONOSCOPY C. Spada ∗ , M.E. Riccioni, L. Petruzziello, P. Cesaro, G. Costamagna Catholic University, Digestive Endoscopy Unit, Roma Background and aim: PillCam Colon Capsule Endoscopy (PCCE) is
an emerging non-invasive method to explore the colon. The preparation (prep) for PCCE lasts longer than that for standard colonoscopy (SC) and requires additional laxatives as it should clean the colon and also facilitate the progression of the capsule. Concerns arise because the large volume of liquids required for PPCE prep may decrease the compliance to the procedure. Aim of this study was to compare the satisfaction between patients (pts) who received 2 different PCCE regimens with those who received SC regimen. Adverse events occurrence was also compared. Material and methods: 40 pts prospectively enrolled in the validation phase of an Italian Multicenter Clinical Trial that evaluates the effect of PCCE prep and procedure on colon cleansing level were compared with a similar group who received prep for SC. Pts were randomized to 2 different PCCE regimens. Regimen I (baseline regimen) included clear liquid diet and 3 liters (L) of PEG on day -1, and 1L PEG in the morning of the procedure day. Additional small doses of NaP boosters were given following capsule ingestion to maintain clean colon and enhance capsule propulsion. Regimen II included low residue diet on days -5 to -2, 4 senna tablets on day -2, clear liquid diet and 3L of PEG on day -1, and PEG instead of NaP boosters on the procedure day. Pts were asked to grade the prep as easy, acceptable, unpleasant, intolerable. They also indicated if they had nausea, vomiting, abdominal pain, headache and vertigo. Pts who received prep for PCCE were compared between the 2 groups and with the group who received prep for SC (low residue diet on days -5 to -1, 4 senna tablets on day -2, 4L of PEG on day -1). Results: No statistical differences were found in term of satisfaction between PCCE regimen I and II, and the SC regimen (Table 1). In addition, no differences were found for adverse events occurrence. Table 1 Prep satisfaction
Easy Acceptable Unpleasant Intolerable
PCCE Regimen I (n=20)
PCCE Regimen II (n=20)
p
PCCE Regimens (n=40)
SC Regimen (n=40)
p
4 11 5 0
4 9 6 1
NS NS NS NS
8 20 11 1
14 14 8 4
NS NS NS NS
Conclusions: PCCE regimens appear as acceptable and as safe as SC regimen. Furthermore, PCCE regimen I (baseline) and regimen II show similar patient’s satisfaction and safety. # Q. Diagnostic endoscopy 6. Video-capsule
P.220 DIFFERENT SEGMENTAL TRANSIT TIME (TT) THROUGH THE SMALL BOWEL MAY AFFECT WIRELESS CAPSULE (WC) ENDOSCOPY N. Pallotta ∗ ,1 , F. Gionata 1 , E. Romeo 2 , M. Cesarini 1 , P. Vernia 1 , S. Cucchiara 2 , E. Corazziari 1 1
Dipartimento di Scienze Cliniche Università Sapienza, Roma; Gastroenterologia ed Epatologia Pediatrica Università Sapienza, Roma 2
Background and aim: Wireless capsule endoscopy (WCE) of the small bowel (SB) cannot be completed in ∼25% of the studies. At WC pyloric and ileo-colonic junction (ICJ) landmarks enable to assess the transit time through the stomach and the SB. However is not known the SB segmental transit times of the WC and whether they might affect the SB WC assessment. After the distension of GI lumen with macrogol solution, ultrasound (US) can assess wall contractions, intraluminal flow, and visualize WC as hyperechoic particle. To assess segmental TT of the WC through the duodenum, the 1st jejunal loop, jejunum, proximal, middle-distal, and terminal ileum. Material and methods: Nine pts (4 F, age 12-70 yrs) with the suspect of SB pathology were assessed. After a 12 hrs fasting period and standard preparation, pts ingested a WC and were submitted to small intestine
Abstracts / Digestive and Liver Disease 41S (2009), S1–S167 contrast ultrasonography (SICUS) after the ingestion of 375-500 ml of macrogol solution (1). With continuous US scanning the transit of the WC was followed through the stomach and the SB until the ICJ and the colon, recorded and later reviewed. Results: At WC the TTthrough the stomach and from the terminal ileum to the colon was 57±47min and 57.5±68min, respectively. At SICUS WC transit through the stomach was 57±47min; through the duodenum, the 1st jejunal loop and jejunum was 4±2min, 7±3min, and 15±14min, respectively, The transit of the WC through the proximal, middle-distal and terminal ileum was 47±34min, 37±22min, and 40±27min, respectively. The passage of the WC through the ICJ into the colon occurred after 71±62min. The slow transit through the ileum and ICJ was due to 1) non propulsive segmenting intestinal contractions causing frequent stops of WC, 2) backward displacement of the WC related to contractions causing ileo-ileal and colon-ileal refluxes (# 13±9.5, range 1-31). A correlation was found between the number of refluxes and time to pass the ICJ (r=0.79, p<0.02). Conclusions: Because of the slow transit of the WC at the level of the ileum and ICJ the WC battery life can end before the WC reaches the colon. The rapid duodenal-jejunal transit of the WC may limit an appropriate assessment of mucosal lesions at this level. The markedly different motor activity of the duodenum, jejunum, ileum and ileo-colonic junction may differently affect a proper and complete WC assessment of the small bowel. 1)Pallotta et al, Lancet 1999 # Q. Diagnostic endoscopy 6. Video-capsule
P.221 FIVE HUNDRED EARLY URGENT ENDOSCOPIES FOR SUSPECTED UPPER GI BLEEDING: ALWAYS NEEDED? ALWAYS EFFECTIVE? T. Togliani ∗ , S. Pilati, N. Mantovani, A. Savioli, C. Pulica, V. Benedini Az. Osp. Carlo Poma, Mantova Background and aim: Upper gastrointestinal bleeding (UGIB) is a severe condition that can be treated endoscopically with success; costeffectiveness of early urgent endoscopy mainly depends on the correct selection of patients. Aim of this single center prospective study was to monitor the appropriateness of early urgent endoscopies for suspected UGIB in terms of patients selection and early outcomes. Material and methods: Five hundred consecutive patients with a first episode of suspected UGIB were included during a period of 29 months. An UGIB was suspected if haematemesis, coffee ground vomit or melaena could be demonstrated. All the patients underwent anamnesis, blood cell count, routine biochemistry and upper GI endoscopy within 6 hours from presentation. According to endoscopic results patients were divided in 4 groups: 1) active bleeding, 2) high risk lesions (white nipples on varices; Forrest IIa-IIb ulcers; Mallory-Weiss tears or Dieulafoy lesions or hemangiomas with an adherent clot), 3) low risk lesions, 4) no lesions; endoscopic therapy was performed in patients included in groups 1 and 2. We compared anamnestic and clinical pre-exam data to endoscopic results, for determining which signs or symptoms could predict the real need of an urgent endoscopic treatment. Statistical validation was evaluated by a χ2 goodness of fit test. Results: Among the 500 patients included 118 (24%) had active bleeding, 70 (14%) had high risk lesions, 187 (37%) had low risk lesions, 125 (25%) had no lesions. The presence of at least 3 characteristics among male sex, haematemesis, anemia, haemodynamic instability or liver cirrhosis predicted the belonging to group 1 or 2, and thus the need of an urgent endoscopic therapy, with an accuracy of only 71% (p<0.05); age, coffee ground vomit, melaena, use of NSAIDs/antiplatelet/anticoagulants or previous upper GI surgery did not show any statistical difference in the 4 groups of patients. Endoscopic treatment obtained an immediate haemostasis in 91% of cases; 4-week relapse rate and bleeding-related mortality rate were 7% and 1% respectively.
S157
Conclusions: Clinical parameters overestimated the bleeding risk and more than half of patients underwent unnecessary early urgent exams; thus an early endoscopic strategy seems adequate only if a very restrictive selection of patients is applied. When actual UGIB is present urgent endoscopic treatment is effective, safe and lasting. # R. Therapeutic endoscopy 1. GI bleeding
P.222 TREATMENT OF MALIGNANT GASTRO-DUODENAL OBSTRUCTION USING A NITINOL SELF EXPANDING METAL STENT (WALLFLEX™) – RESULTS OF A SINGLE CENTER FROM AN INTERNATIONAL PROSPECTIVE REGISTRY G. Costamagna, A. Tringali ∗ , M. Mutignani, P. Familiari, V. Perri Digestive Endoscopy Unit - Catholic University, Roma Background and aim: To document technical and clinical success, and complications associated with use of the WallFlex™ Duodenal Stent (Boston Scientific Corp, Natick, USA) for the palliative management of malignant gastro-duodenal obstruction in a large international multicentric experience. Results of the Italian experience from a single center participating to an international registry are reported. Material and methods: A web-based prospective registry is conducted at 12 endoscopy centers in 10 countries. Follow-up to 9 months is ongoing. An interim analysis of patients enrolled at the Digestive Endoscopy Unit – Catholic University of Rome, is reported. Results: 64/208 patients (mean age 73 years, 36 male) were enrolled at the Catholic University of Rome. Most common causes of the stricture were pancreatic cancer (50%), gastric cancer (14%), lymphnodal metastases (14%), duodenal cancer (9%), cholangiocarcinoma (8%) and gallbladder cancer (5%). Stent length was 6 cm (65%), 9 cm (32%), or 12 cm (3%). Technical success was achieved in 100% (64/64). Gastric Outlet Obstruction (GOO) improved from 3% of patients at Baseline tolerating soft solids or low residue/normal diet to 88% at 15 days, 88% at 30 days, 92% at 90 days, and 89% at 180 days. At 90 days post stent placement compared to Baseline, symptoms of post-prandial epigastric tenderness, nausea and vomiting improved in 71%, 75% and 87% of patients respectively and did not worsen in 100% for all three symptoms. One patient (1.6%) had abdominal pain after stent insertion treated by NSAID and then resolved. No other complication during the first week after duodenal WallflexTM insertion were recorded. GOO recurrence during follow-up was due to tumor ingrowth (14%), gastric paresis (6.3%) and tumor ingrowth+overgrowth (4.7%). Retreatment occurred in 9 patients (12.5%) and all received another self-expanding metal stent. To date 84.4% patients died, none due to stent or stenting related complications. Mean survival (to the last available follow-up or death) was 93 days. Conclusions: Preliminary results from a center of this International Registry related to the WallFlex™ Duodenal Stent, confirm the effectiveness of the endoscopic treatment of GOO with SEMS with acceptable complication profile. Endoscopic re-treatment of malfunctioning (ingrowth/overgrowth) or migrated SEMS is possible. # R. Therapeutic endoscopy 2. Stenosis palliation
P.223 TRANSNASAL VERSUS ORAL PEG PLACEMENT IN UNSELECTED PATIENTS: A PROSPECTIVE RANDOMIZED CLINICAL TRIAL I. Stroppa ∗ , R. Lionetti, A. Cocco, F. Andrei, M. Erboso, F. Pallone Policlinico Tor Vergata, Roma Background and aim: Conventional transoral PEG (O-PEG) is not always possible to perform due to neurological or oro-pharyngeal dis-