- Email: [email protected]
Mo1115 Comparison of Modified and Full Glasgow-Blatchford Scores Performance in Patients With Non-Variceal Upper Gastrointestinal Bleeding
Abstracts
visibility of short segment Barrett’s esophagus compared with WLI. Interrater reliability is substantial for experts endoscopists and moderate for trainee endoscopists.
Mo1113 Adverse Events During Endoscopy With and Without the Presence of an Endoscopy Nurse When Sedation Is Administered by an Anesthesia Specialist Deepak Agrawal*1, Pamela Lovett2, Kevin Brodersen2, Zhouwen Tang1, Rajeev Jain3, John A. Martin4, Michael B. Wallace5, Elizabeth Rajan4 1 University Texas Southwestern, Dallas, TX; 2Anesthesiology, Mayo Clinic, Jacksonville, FL; 3Digestive and Liver Diseases, Presbyterian Hospital, Dallas, TX; 4Gastroenterology, Mayo Clinic, Rochester, MN; 5 Gastroenterology, Mayo Clinic, Jacksonville, FL Background: Endoscopic procedures may be performed under “moderate” or “deep” sedation. Moderate sedation is typically administered by registered nurses (RNs) under supervision of the endoscopist. Deep sedation includes propofol-based anesthesia or mechanical ventilation that is administered by an anesthesia specialist. The role of RNs during endoscopic procedures is debated, and guidelines therein unclear, when their main responsibility of administering sedation is taken over by an anesthesia specialist. Aims: Determine adverse events related to endoscopic procedure and sedation, with and without the presence of an endoscopy nurse (RN), when sedation is administered by an anesthesia specialist (CRNA – certified registered nurse anesthetist). Methods: Retrospective review of consecutive outpatient upper gastrointestinal endoscopies and colonoscopies with deep sedation, administered by an anesthesia specialist, performed at two tertiary referral hospitals with different staffing models – one where only a CRNA is present (A) and the other where an RN is present along with a CRNA (A+RN). Exclusion criteria included advanced endoscopic procedures such as endoscopic mucosal resection, submucosal dissection, and ASA class IV patients. Significant adverse events were defined as those requiring unplanned admissions, escalation to higher level of care, or death. These included procedure-related adverse events such as perforation, and bleeding requiring transfusion. Sedation-related adverse events included need for cardiopulmonary resuscitation, and hypotension or hypoxia requiring premature termination of procedure. Results: There were 106 patients in group A and 109 patients in group A+RN. Patients in the A+RN group were significantly older and had a higher frequency of ASA III classification. There were no differences in body mass index, type of procedures, or procedure duration. Significantly higher dosages of propofol were used in A+RN group. Fentanyl was predominantly used along with propofol only in the A group, due to difference in institutional practices. There were no sedationrelated adverse events in either group. There were three procedure-related adverse events in the A group – 2 patients with perforations and one with bleeding who was admitted for observation. There was no significant difference in either sedationrelated or endoscopy-related adverse events between the two groups (Table 1). Conclusion: Presence of an RN during procedure along with an anesthesiology specialist does not affect the adverse events of the procedure or sedation and may not be necessary.
Number of patients Age [y], mean (CI) ASA classification (%) I II III BMI, mean (CI) Type of procedure, n Upper Endoscopy Colonoscopy Procedure duration [min], mean (CI) Adverse Events, n Sedation related Procedure related Medication dose Propofol [mg), mean (CI) Fentanyl (mcg), N 0 25 50 75 100 150
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Anesthesia specialist 106 55.5 (52.4-58.6)
Anesthesia specialist + RN 109 65.6 (62.8-68.4)
3 (3%) 72 (68%) 31 (29%) 28.2 (26.7-29.9)
1 (1%) 40 (37%) 68 (62%) 29 (27.5-30.4)
44 (42%) 62 (58%) 16 (13.5-18.6) 0 3
39 (36%) 70 (64%) 24.7 (8.5-40.8) 0 0
124.7 (98.1-151.3)
392.6 (226.4 – 294.7)
14 3 22 4 62 1
105 0 1 0 3 0
< 0.001 < 0.001
0.53 0.39
0.30 0 0.08
< 0.001 < 0.001
Mo1114 Underwater EMR Is a Safe Procedure That Can Be by an Endoscopist Trained in Traditional Emr: The Experience of Two UK Centres Abdulkani Yusuf*1, Noriko Suzuki1, Keith Siau2, Sauid Ishaq2,3 1 Wolfson Unit for Endoscopy, St Mark’s Hospital, London, United Kingdom; 2Department of Gastroenterology, Russells Hall Hospital, Dudley, United Kingdom; 3Birmingham City University, Birmingham, United Kingdom Introduction: Underwater EMR (UEMR) is a relatively new technique, where air or CO2 insufflation is not required when performing EMR. We present here the experience of two UK centres. Aims & Methods: The aim of this study was to assess the 1) feasibility of UEMR by endoscopists trained in traditional EMR, and 2) to assess the safety, tolerability, and effectiveness of UEMR. All procedures were performed by two experienced endoscopists at St Mark’s hospital in London and at Russells Hall hospital in Dudley, UK. To improve the views and increase the safety of the procedure, we employed a “hybrid technique” with injection of lifting solution if a lesion was traversing a fold, or if a lesion was removed in a retroflexion, as a case of perforation in a retroflexed position during UEMR was recently described1. Argon Plasma Coagulation (APC) was used if there was remnant tissue post resection. Results: From February 2015 to October 2016, a total of 53 patients (mean age 66.36 years, males nZ 33) had UEMR of 58 lesions. The lesions (mean size 32.6 mm, range 7-160 mm) were located in right colon (n Z 9), transverse colon (nZ 2), left colon (nZ14), and rectum (nZ 33). 8 of the lesions (13.8 %) were recurrence post previous traditional EMR. The morphology of the lesions were either flat (nZ30) or sessile (nZ28). Hybrid technique and APC were employed as following: Lifting (nZ18), APC (nZ 4), and a combination of lifting and APC (nZ 2). Histology of the lesions showed low grade dysplasia (nZ 45), high grade dysplasia (nZ 9), cancer (nZ2), and other (nZ2). Complete endoscopic resection was achieved in 57 out of the 58 lesions (98.3%); One patient declined the intervention before the lesion was fully resected. There were no perforations, but there were two cases of immediate bleeding (3.8%), which were controlled endoscopically, and one case of delayed bleeding (1.9 %), which required endoscopic intervention. The procedures, which were performed either with no sedation or analgesia (n Z 19), with light sedation and analgesia (nZ 26), or with nitrous oxide/oxygen inhalation (n Z 8), were welltolerated with a pain score of zero or one (zero Z no pain; one Z minimal pain). Conclusion: UEMR seems to be an effective, safe and a well-tolerated procedure, which can be performed by an endoscopist trained in traditional EMR. It can be an alternative to the traditional EMR, which requires air or CO2 insufflation, which significantly thins the colonic wall, and hence increases the risk of complication. The underwater immersion creates a floating effect, which keeps apart mucosa and submucosa, making UEMR technically easier and safer than traditional EMR2. Follow-up data is required to assess the short- and long-term recurrence rate associated with UEMR. References 1. Ponugoti PL, et al. GIE. 2016 Sep;84(3):543-4. 2. Ishaq S, et al. Endoscopy. 2016 0;48(S 01):E371.
Mo1115 Comparison of Modified and Full Glasgow-Blatchford Scores Performance in Patients With Non-Variceal Upper Gastrointestinal Bleeding Evgeny A. Idrisov*, Sameen Khalid, Xiaoping He, Win Ko, Christopher Armstrong, Christian ColonRipoll, Fnu Asad-Ur-Rahman, Khalid Abusaada Internal Medicine Residency, Florida Hospital Orlando, Maitland, FL Objective: Acute upper gastrointestinal bleeding (UGIB) is a common medical emergency with an incidence of 100 per 100,000 population per year. Patients with acute UGIB mostly present with one or more symptoms including hematemesis, melena, hematochezia and occult blood loss. Several scoring systems have been developed to stratify the risk of complications and resource allocation for management of patients presenting with UGIB. Among them, Glasgow-Blatchford (GBS) score has been extensively evaluated and compared with other scoring systems for risk stratification. Subsequently, a modified GBS was developed to predict outcomes in UGIB. The advantage of modified GBS is that it eliminates subjective components of the full score and it is calculated using number of objective clinical and laboratory variables, thus making it helpful in patients who are unable to provide adequate medical history. Aim: To externally validate the modified GBS with full GBS for prediction of major clinical outcomes in patients with UGIB. Methods: A retrospective cohort study of patients over age of 18 years admitted in 2015 to a tertiary care center with non-variceal GI bleeding was done. Patients with a history of liver cirrhosis or variceal bleeding were excluded. Our primary outcome was composite of: 1) inpatient mortality; 2) need for endoscopic, surgical or radiologic procedure to control the bleed or to treat the underlying source of the bleed; 3) need for blood transfusion; 4) rebleed in the hospital. Comparison of the two scores was done using area under operating the receiver operating characteristics curve. Results: 314 patients were included in the study. Median age was 65.7 years. In-hospital mortality was 2.5% (8 patients). An intervention to control the bleeding was performed in 90 patients (28.7%) while 52.0% (163 patients) required PRBC transfusion (Table 1). Analysis of area under receiver operating characteristic revealed that performance of
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB433
Abstracts
the modified GBS score (AUROC 0.76, 95% CI 0.70 - 0.82) was comparable to full GBS (AUROC 0.76, 95% CI 0.70 - 0.82) in predicting in-hospital mortality or need for any therapeutic endoscopic, surgical or radiologic intervention or PRBC transfusion (Figure 1). Sensitivity and specificity of full GBS score 1 for predicting the primary outcome was 98.9% and 10.26% respectively, modified GBS had a sensitivity and a specificity of 97.46% and 19.66% respectively. Conclusions: In patients with nonvariceal UGIB; modified GBS performed as well as full GBS score in predicting complications and the need for hospital based interventions. Modified GBS is simple to calculate and can serve as an objective tool for risk stratification of patients presenting with non-variceal UGIB.
Clinical Characteristics Total patients Age, mean (SD), years Gender - Male, N (%) Presenting Symptom Hematemesis, N (%) Melena, N (%) Hematochezia, N (%) Syncope, N (%) Endoscopy EGD only, N (%) CSP only, N (%) EGD and CSP, N (%) None, N (%) Causes of GI bleed Peptic ulcer disease, N (%) Erosive esophagitis/gastritis/duodenitis, N (%) Mallory-Weiss Tear, N (%) Gastric/duodenal AVM, N(%) Esophageal / gastric malignancy, N (%) Other, N (%) Primary Outcomes In-patient mortality, N (%) PRBC transfusion, N (%) Endoscopic intervention to control bleeding, N (%) Type of Intervention Coagulation/Cautherization, N (%) Epinephrine treatment, N (%) Hemocliping, N (%) Arterial embolization / Surgery, N (%) Other, N (%)
314 65.7 (1.04) 184 (58.60) 90 (28.66) 201 (64.01) 56 (17.83) 30 (9.55) 224 (71.34) 4 (1.27) 53 (16.88) 33 (10.51) 154 (49.04) 188 (59.87) 15 (4.78) 28 (8.92) 4 (1.27) 8 (2.55)
Introduction: Despite the advantages of endoscopic submucosal resection (ESD) demonstrated in large series from the east, the procedure is not commonly practiced in the west and its role in standard practice is still debated. Although limited evidence regarding its efficacy in European practice is emerging, very few centres in the United Kingdom perform ESD. We report the experience of a tertiary referral institution using ESD as part of a lesion specific, pragmatic approach to endoscopic resection in a complex patient cohort. Methods: Patients who underwent ESD of colorectal lesions were included. Lesions were assessed with magnification chromoendoscopy supplemented by colonoscopic ultrasound in selected cases. A lesion specific approach was used to decide on resection technique, which included assessment of morphology, pit pattern, risk of submucosal invasion, and presence of submucosal fibrosis or scarring. ESD was used where en bloc resection was deemed essential, or as part of a hybrid procedure to ensure resection of a dominant nodule or suspicious area of a lesion in one piece, or where fibrosis or scarring would make standard EMR impossible. A resection was designated a hybrid procedure if ESD was used to effect submucosal dissection, circumferential incision alone to assist snare resection was not included. Results: 435 colorectal lesions 2cm were resected. ESD was used in 97 cases, 49 cases used ESD alone and 48 as part of a hybrid procedure. 74% of these had 1 or more failed attempts at resection or significant manipulation in the form of 6 or more biopsies or tattoo into the lesion prior to referral to our institution. Only 8 of the remaining patients had no prior biopsies performed. The mean lesion size was 63mm. En bloc resection was achieved in 89.8% where ESD was used alone, with a recurrence rate of 5.3% after a mean follow up of 13.3 months. There were 6 microperforations treated with either endoscopic clips or antibiotics alone with no adverse sequelae, and one clinically significant perforation requiring surgery. However, the resected lesion in this case contained an invasive adenocarcinoma with deep submucosal invasion – there was no residual tumour in the surgical resection specimen. Post-procedure bleeding occurred in 6 patients, none of whom required additional interventional therapy. 71% of cases were successfully performed as day case procedures. 97% of patients without invasive cancer were free from recurrence and had avoided surgery at last follow up. Conclusion: ESD can be safely and effectively incorporated into European practice as an essential adjunct in the treatment of a particularly complex patient cohort. As a result of large lesion size and very high rates of previous significant manipulation of lesions by the time of referral, a pragmatic, lesion-specific approach in choosing the resection technique is recommended.
8 (2.55) 163 (51.91) 90 (28.66) 68 (21.66) 48 (15.29) 23 (7.32) 4 (1.27) 3 (0.96)
Mo1116 Endoscopic Submucosal Dissection for Colorectal Neoplasia: The Experience of a UK Tertiary Referral Centre Andrew Emmanuel*1, Shraddha Gulati2, Margaret Burt1, Bu Hayee2, Amyn Haji1 1 Colorectal Surgery, King’s College Hospital, London, United Kingdom; 2 Gastroenterology, King’s College Hospital, London, United Kingdom
AB434 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Mo1117 Risk Factors for Metachronous Gastric Adenocarcinoma Development After Endoscopic Resection of Gastric Dysplasia Hee Seok Moon*, Hyun Yong Jeong, Jaekyu Sung gastroenteology, chungnam national university hospital, Daejeon, — Select —, Korea (the Republic of) Background/Aims: Gastric dysplasia is a precursor lesion of an invasive adenocarcinoma. Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is routinely performed for removal of this premalignant lesion. After the removal of the lesion, a gastric adenocarcinoma (GAC) is sometimes detected during the follow-up period. The literature on factors associated with gastric cancer occurrence is scarce. To shed light on the occurrence rate of GAC and related factors, the follow-up results of patients who had been confirmed with gastric dysplasia after endoscopic resection were evaluated. Methods: This was a retrospective analysis of the medical records, endoscopic examination records, endoscopic procedure records, and histological records of 1,273 patients diagnosed with gastric dysplasia after undergoing EMR or ESD for gastric mucosal lesions between January 2007 and August 2013 at the Chungnam National University Hospital. The study consisted of data on 667 lesions in 641 patients. Results: The mean follow-up period was 33.8 months, and the median follow-up period was 29 months (range, 12–87). During the follow-up period, the incidence of metachronous GAC was 4.0% (27/667). The mean and median interval between the occurrence of metachronous GAC and endoscopic treatment of GA was 36.3 months and 34 months, respectively (range, 16–71). The factors related to the occurrence of metachronous GAC after endoscopic resection for gastric dysplasia were male sex (5.3% vs. 1.0%), open type of atrophic gastritis (9.5% vs. 3.4%), intestinal metaplasia (6.8% vs. 2.4%), and high-grade dysplasia (8.4% vs. 3.2%). Among these factors, male sex (odds ratio [OR]: 5.05(1.18–21.68),pZ0.029), intestinal metaplasia (OR: 2.78(1.24–6.23),pZ0.013), and high-grade dysplasia (OR: 2.70(1.16–6.26),pZ0.021］were independent risk factors in a multivariate analysis. Of the 27 cases of GAC, 24 (88.9%) occurred at locations other than the original resection sites, and 3 (11.1%) occurred at the same location as the previous resection site. Conclusions: Male sex, intestinal metaplasia, and high-grade dysplasia were significantly related to the occurrence of metachronous GAC after EMR/ESD for gastric dysplasia, and most dysplasic lesions occurred at sites other than the original resection sites. Keywords: Gastric dysplasia, Endoscopic mucosal resection, Endoscopic submucosal dissection, Metachronous, Gastric adenocarcinoma
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visibility of short segment Barrett’s esophagus compared with WLI. Interrater reliability is substantial for experts endoscopists and moderate for trainee endoscopists.
Mo1113 Adverse Events During Endoscopy With and Without the Presence of an Endoscopy Nurse When Sedation Is Administered by an Anesthesia Specialist Deepak Agrawal*1, Pamela Lovett2, Kevin Brodersen2, Zhouwen Tang1, Rajeev Jain3, John A. Martin4, Michael B. Wallace5, Elizabeth Rajan4 1 University Texas Southwestern, Dallas, TX; 2Anesthesiology, Mayo Clinic, Jacksonville, FL; 3Digestive and Liver Diseases, Presbyterian Hospital, Dallas, TX; 4Gastroenterology, Mayo Clinic, Rochester, MN; 5 Gastroenterology, Mayo Clinic, Jacksonville, FL Background: Endoscopic procedures may be performed under “moderate” or “deep” sedation. Moderate sedation is typically administered by registered nurses (RNs) under supervision of the endoscopist. Deep sedation includes propofol-based anesthesia or mechanical ventilation that is administered by an anesthesia specialist. The role of RNs during endoscopic procedures is debated, and guidelines therein unclear, when their main responsibility of administering sedation is taken over by an anesthesia specialist. Aims: Determine adverse events related to endoscopic procedure and sedation, with and without the presence of an endoscopy nurse (RN), when sedation is administered by an anesthesia specialist (CRNA – certified registered nurse anesthetist). Methods: Retrospective review of consecutive outpatient upper gastrointestinal endoscopies and colonoscopies with deep sedation, administered by an anesthesia specialist, performed at two tertiary referral hospitals with different staffing models – one where only a CRNA is present (A) and the other where an RN is present along with a CRNA (A+RN). Exclusion criteria included advanced endoscopic procedures such as endoscopic mucosal resection, submucosal dissection, and ASA class IV patients. Significant adverse events were defined as those requiring unplanned admissions, escalation to higher level of care, or death. These included procedure-related adverse events such as perforation, and bleeding requiring transfusion. Sedation-related adverse events included need for cardiopulmonary resuscitation, and hypotension or hypoxia requiring premature termination of procedure. Results: There were 106 patients in group A and 109 patients in group A+RN. Patients in the A+RN group were significantly older and had a higher frequency of ASA III classification. There were no differences in body mass index, type of procedures, or procedure duration. Significantly higher dosages of propofol were used in A+RN group. Fentanyl was predominantly used along with propofol only in the A group, due to difference in institutional practices. There were no sedationrelated adverse events in either group. There were three procedure-related adverse events in the A group – 2 patients with perforations and one with bleeding who was admitted for observation. There was no significant difference in either sedationrelated or endoscopy-related adverse events between the two groups (Table 1). Conclusion: Presence of an RN during procedure along with an anesthesiology specialist does not affect the adverse events of the procedure or sedation and may not be necessary.
Number of patients Age [y], mean (CI) ASA classification (%) I II III BMI, mean (CI) Type of procedure, n Upper Endoscopy Colonoscopy Procedure duration [min], mean (CI) Adverse Events, n Sedation related Procedure related Medication dose Propofol [mg), mean (CI) Fentanyl (mcg), N 0 25 50 75 100 150
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Anesthesia specialist 106 55.5 (52.4-58.6)
Anesthesia specialist + RN 109 65.6 (62.8-68.4)
3 (3%) 72 (68%) 31 (29%) 28.2 (26.7-29.9)
1 (1%) 40 (37%) 68 (62%) 29 (27.5-30.4)
44 (42%) 62 (58%) 16 (13.5-18.6) 0 3
39 (36%) 70 (64%) 24.7 (8.5-40.8) 0 0
124.7 (98.1-151.3)
392.6 (226.4 – 294.7)
14 3 22 4 62 1
105 0 1 0 3 0
< 0.001 < 0.001
0.53 0.39
0.30 0 0.08
< 0.001 < 0.001
Mo1114 Underwater EMR Is a Safe Procedure That Can Be by an Endoscopist Trained in Traditional Emr: The Experience of Two UK Centres Abdulkani Yusuf*1, Noriko Suzuki1, Keith Siau2, Sauid Ishaq2,3 1 Wolfson Unit for Endoscopy, St Mark’s Hospital, London, United Kingdom; 2Department of Gastroenterology, Russells Hall Hospital, Dudley, United Kingdom; 3Birmingham City University, Birmingham, United Kingdom Introduction: Underwater EMR (UEMR) is a relatively new technique, where air or CO2 insufflation is not required when performing EMR. We present here the experience of two UK centres. Aims & Methods: The aim of this study was to assess the 1) feasibility of UEMR by endoscopists trained in traditional EMR, and 2) to assess the safety, tolerability, and effectiveness of UEMR. All procedures were performed by two experienced endoscopists at St Mark’s hospital in London and at Russells Hall hospital in Dudley, UK. To improve the views and increase the safety of the procedure, we employed a “hybrid technique” with injection of lifting solution if a lesion was traversing a fold, or if a lesion was removed in a retroflexion, as a case of perforation in a retroflexed position during UEMR was recently described1. Argon Plasma Coagulation (APC) was used if there was remnant tissue post resection. Results: From February 2015 to October 2016, a total of 53 patients (mean age 66.36 years, males nZ 33) had UEMR of 58 lesions. The lesions (mean size 32.6 mm, range 7-160 mm) were located in right colon (n Z 9), transverse colon (nZ 2), left colon (nZ14), and rectum (nZ 33). 8 of the lesions (13.8 %) were recurrence post previous traditional EMR. The morphology of the lesions were either flat (nZ30) or sessile (nZ28). Hybrid technique and APC were employed as following: Lifting (nZ18), APC (nZ 4), and a combination of lifting and APC (nZ 2). Histology of the lesions showed low grade dysplasia (nZ 45), high grade dysplasia (nZ 9), cancer (nZ2), and other (nZ2). Complete endoscopic resection was achieved in 57 out of the 58 lesions (98.3%); One patient declined the intervention before the lesion was fully resected. There were no perforations, but there were two cases of immediate bleeding (3.8%), which were controlled endoscopically, and one case of delayed bleeding (1.9 %), which required endoscopic intervention. The procedures, which were performed either with no sedation or analgesia (n Z 19), with light sedation and analgesia (nZ 26), or with nitrous oxide/oxygen inhalation (n Z 8), were welltolerated with a pain score of zero or one (zero Z no pain; one Z minimal pain). Conclusion: UEMR seems to be an effective, safe and a well-tolerated procedure, which can be performed by an endoscopist trained in traditional EMR. It can be an alternative to the traditional EMR, which requires air or CO2 insufflation, which significantly thins the colonic wall, and hence increases the risk of complication. The underwater immersion creates a floating effect, which keeps apart mucosa and submucosa, making UEMR technically easier and safer than traditional EMR2. Follow-up data is required to assess the short- and long-term recurrence rate associated with UEMR. References 1. Ponugoti PL, et al. GIE. 2016 Sep;84(3):543-4. 2. Ishaq S, et al. Endoscopy. 2016 0;48(S 01):E371.
Mo1115 Comparison of Modified and Full Glasgow-Blatchford Scores Performance in Patients With Non-Variceal Upper Gastrointestinal Bleeding Evgeny A. Idrisov*, Sameen Khalid, Xiaoping He, Win Ko, Christopher Armstrong, Christian ColonRipoll, Fnu Asad-Ur-Rahman, Khalid Abusaada Internal Medicine Residency, Florida Hospital Orlando, Maitland, FL Objective: Acute upper gastrointestinal bleeding (UGIB) is a common medical emergency with an incidence of 100 per 100,000 population per year. Patients with acute UGIB mostly present with one or more symptoms including hematemesis, melena, hematochezia and occult blood loss. Several scoring systems have been developed to stratify the risk of complications and resource allocation for management of patients presenting with UGIB. Among them, Glasgow-Blatchford (GBS) score has been extensively evaluated and compared with other scoring systems for risk stratification. Subsequently, a modified GBS was developed to predict outcomes in UGIB. The advantage of modified GBS is that it eliminates subjective components of the full score and it is calculated using number of objective clinical and laboratory variables, thus making it helpful in patients who are unable to provide adequate medical history. Aim: To externally validate the modified GBS with full GBS for prediction of major clinical outcomes in patients with UGIB. Methods: A retrospective cohort study of patients over age of 18 years admitted in 2015 to a tertiary care center with non-variceal GI bleeding was done. Patients with a history of liver cirrhosis or variceal bleeding were excluded. Our primary outcome was composite of: 1) inpatient mortality; 2) need for endoscopic, surgical or radiologic procedure to control the bleed or to treat the underlying source of the bleed; 3) need for blood transfusion; 4) rebleed in the hospital. Comparison of the two scores was done using area under operating the receiver operating characteristics curve. Results: 314 patients were included in the study. Median age was 65.7 years. In-hospital mortality was 2.5% (8 patients). An intervention to control the bleeding was performed in 90 patients (28.7%) while 52.0% (163 patients) required PRBC transfusion (Table 1). Analysis of area under receiver operating characteristic revealed that performance of
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB433
Abstracts
the modified GBS score (AUROC 0.76, 95% CI 0.70 - 0.82) was comparable to full GBS (AUROC 0.76, 95% CI 0.70 - 0.82) in predicting in-hospital mortality or need for any therapeutic endoscopic, surgical or radiologic intervention or PRBC transfusion (Figure 1). Sensitivity and specificity of full GBS score 1 for predicting the primary outcome was 98.9% and 10.26% respectively, modified GBS had a sensitivity and a specificity of 97.46% and 19.66% respectively. Conclusions: In patients with nonvariceal UGIB; modified GBS performed as well as full GBS score in predicting complications and the need for hospital based interventions. Modified GBS is simple to calculate and can serve as an objective tool for risk stratification of patients presenting with non-variceal UGIB.
Clinical Characteristics Total patients Age, mean (SD), years Gender - Male, N (%) Presenting Symptom Hematemesis, N (%) Melena, N (%) Hematochezia, N (%) Syncope, N (%) Endoscopy EGD only, N (%) CSP only, N (%) EGD and CSP, N (%) None, N (%) Causes of GI bleed Peptic ulcer disease, N (%) Erosive esophagitis/gastritis/duodenitis, N (%) Mallory-Weiss Tear, N (%) Gastric/duodenal AVM, N(%) Esophageal / gastric malignancy, N (%) Other, N (%) Primary Outcomes In-patient mortality, N (%) PRBC transfusion, N (%) Endoscopic intervention to control bleeding, N (%) Type of Intervention Coagulation/Cautherization, N (%) Epinephrine treatment, N (%) Hemocliping, N (%) Arterial embolization / Surgery, N (%) Other, N (%)
314 65.7 (1.04) 184 (58.60) 90 (28.66) 201 (64.01) 56 (17.83) 30 (9.55) 224 (71.34) 4 (1.27) 53 (16.88) 33 (10.51) 154 (49.04) 188 (59.87) 15 (4.78) 28 (8.92) 4 (1.27) 8 (2.55)
Introduction: Despite the advantages of endoscopic submucosal resection (ESD) demonstrated in large series from the east, the procedure is not commonly practiced in the west and its role in standard practice is still debated. Although limited evidence regarding its efficacy in European practice is emerging, very few centres in the United Kingdom perform ESD. We report the experience of a tertiary referral institution using ESD as part of a lesion specific, pragmatic approach to endoscopic resection in a complex patient cohort. Methods: Patients who underwent ESD of colorectal lesions were included. Lesions were assessed with magnification chromoendoscopy supplemented by colonoscopic ultrasound in selected cases. A lesion specific approach was used to decide on resection technique, which included assessment of morphology, pit pattern, risk of submucosal invasion, and presence of submucosal fibrosis or scarring. ESD was used where en bloc resection was deemed essential, or as part of a hybrid procedure to ensure resection of a dominant nodule or suspicious area of a lesion in one piece, or where fibrosis or scarring would make standard EMR impossible. A resection was designated a hybrid procedure if ESD was used to effect submucosal dissection, circumferential incision alone to assist snare resection was not included. Results: 435 colorectal lesions 2cm were resected. ESD was used in 97 cases, 49 cases used ESD alone and 48 as part of a hybrid procedure. 74% of these had 1 or more failed attempts at resection or significant manipulation in the form of 6 or more biopsies or tattoo into the lesion prior to referral to our institution. Only 8 of the remaining patients had no prior biopsies performed. The mean lesion size was 63mm. En bloc resection was achieved in 89.8% where ESD was used alone, with a recurrence rate of 5.3% after a mean follow up of 13.3 months. There were 6 microperforations treated with either endoscopic clips or antibiotics alone with no adverse sequelae, and one clinically significant perforation requiring surgery. However, the resected lesion in this case contained an invasive adenocarcinoma with deep submucosal invasion – there was no residual tumour in the surgical resection specimen. Post-procedure bleeding occurred in 6 patients, none of whom required additional interventional therapy. 71% of cases were successfully performed as day case procedures. 97% of patients without invasive cancer were free from recurrence and had avoided surgery at last follow up. Conclusion: ESD can be safely and effectively incorporated into European practice as an essential adjunct in the treatment of a particularly complex patient cohort. As a result of large lesion size and very high rates of previous significant manipulation of lesions by the time of referral, a pragmatic, lesion-specific approach in choosing the resection technique is recommended.
8 (2.55) 163 (51.91) 90 (28.66) 68 (21.66) 48 (15.29) 23 (7.32) 4 (1.27) 3 (0.96)
Mo1116 Endoscopic Submucosal Dissection for Colorectal Neoplasia: The Experience of a UK Tertiary Referral Centre Andrew Emmanuel*1, Shraddha Gulati2, Margaret Burt1, Bu Hayee2, Amyn Haji1 1 Colorectal Surgery, King’s College Hospital, London, United Kingdom; 2 Gastroenterology, King’s College Hospital, London, United Kingdom
AB434 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Mo1117 Risk Factors for Metachronous Gastric Adenocarcinoma Development After Endoscopic Resection of Gastric Dysplasia Hee Seok Moon*, Hyun Yong Jeong, Jaekyu Sung gastroenteology, chungnam national university hospital, Daejeon, — Select —, Korea (the Republic of) Background/Aims: Gastric dysplasia is a precursor lesion of an invasive adenocarcinoma. Endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is routinely performed for removal of this premalignant lesion. After the removal of the lesion, a gastric adenocarcinoma (GAC) is sometimes detected during the follow-up period. The literature on factors associated with gastric cancer occurrence is scarce. To shed light on the occurrence rate of GAC and related factors, the follow-up results of patients who had been confirmed with gastric dysplasia after endoscopic resection were evaluated. Methods: This was a retrospective analysis of the medical records, endoscopic examination records, endoscopic procedure records, and histological records of 1,273 patients diagnosed with gastric dysplasia after undergoing EMR or ESD for gastric mucosal lesions between January 2007 and August 2013 at the Chungnam National University Hospital. The study consisted of data on 667 lesions in 641 patients. Results: The mean follow-up period was 33.8 months, and the median follow-up period was 29 months (range, 12–87). During the follow-up period, the incidence of metachronous GAC was 4.0% (27/667). The mean and median interval between the occurrence of metachronous GAC and endoscopic treatment of GA was 36.3 months and 34 months, respectively (range, 16–71). The factors related to the occurrence of metachronous GAC after endoscopic resection for gastric dysplasia were male sex (5.3% vs. 1.0%), open type of atrophic gastritis (9.5% vs. 3.4%), intestinal metaplasia (6.8% vs. 2.4%), and high-grade dysplasia (8.4% vs. 3.2%). Among these factors, male sex (odds ratio [OR]: 5.05(1.18–21.68),pZ0.029), intestinal metaplasia (OR: 2.78(1.24–6.23),pZ0.013), and high-grade dysplasia (OR: 2.70(1.16–6.26),pZ0.021］were independent risk factors in a multivariate analysis. Of the 27 cases of GAC, 24 (88.9%) occurred at locations other than the original resection sites, and 3 (11.1%) occurred at the same location as the previous resection site. Conclusions: Male sex, intestinal metaplasia, and high-grade dysplasia were significantly related to the occurrence of metachronous GAC after EMR/ESD for gastric dysplasia, and most dysplasic lesions occurred at sites other than the original resection sites. Keywords: Gastric dysplasia, Endoscopic mucosal resection, Endoscopic submucosal dissection, Metachronous, Gastric adenocarcinoma
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