P.16.11 SIMULTANEOUS ONE-PIECE ENDOSCOPIC SUBMUCOSAL DISSECTION FOR TWO POORLY DIFFERENTIATED EARLY GASTRIC CANCER IN ELDERLY PATIENT

Abstracts of the 22nd National Congress of Digestive Diseases / Digestive and Liver Disease 48S2 (2016) e67–e231

admission, reduces timing of procedures actuation and allows a faster and appropriate therapy.

P.16.9 DOES URGENT COLONOSCOPY FOR LOWER GASTROINTESTINAL BLEEDING NEED ORAL BOWEL PREPARATION? Vitale G.*, Tremolaterra F., Iosca N., Sigillito A.R. Ospedale “San Carlo”, Potenza, Italy Background and aim: Acute Lower GastroIntestinal Bleeding (LGIB) represents a quarter of all bleeding events with a progressive increased annual incidence. Colonoscopy is recommended in the early evaluation of LGIB. It is suggested that bowel preparation improves endoscopic visualization, diagnostic yield and safety of the procedure. In clinical practice, it can be difficult to perform bowel preparation in emergencies, maybe delaying times for colonoscopy. Material and methods: From July 2014 to October 2015 we analyzed retrospectively data from patients (pts) affected by LGIB undergoing urgent colonoscopy in our Endoscopic Unit. Pts characteristics, endoscopic diagnostic/therapeutic results and clinical outcome were submitted to statistical analysis. Results: Overall, 40 pts with LGIB (F/M ratio 1:1, mean age 70 years) were included in the analysis. As expected, 65% of pts were on antiplatelet or anticoagulation therapy. All the pts performed colonoscopy within 24 hours. The 77,5% of colonoscopy (31/40 pts) had a early and satisfactory diagnostic yield. The diagnostic ability was superior for the left colon compared to the right colon lesions (20 vs 7 lesions). In the left colon were found 24 bleeding lesions: 6 rectal ulcers, 4 diverticula, 4 ischemic colitis, 3 post-polypectomy bleeding, 2 other colitis, 2 polyps/neoplasia, 2 radiation proctitis, 1 hemorrhoids while only 7 bleeding sources were found in the right colon (2 diverticula, 2 postpolypectomy bleeding, 3 small bowel bleeding). Where the bleeding source was not identified (9/40 pts; 22,5%), complete colonoscopy after bowel preparation showed 3 right colon angiodysplasias and 2 right diverticular bleeding self-limited. Overall, 35,5% (11/31) of pts had active bleeding endoscopically treated (clips or clips plus epinephrine). Two pts were referred to surgical treatment (ischemic colitis), while the other pts received medical treatment. Conclusions: In our experience, peristaltic water pump cleaning use during urgent colonoscopy without bowel preparation, is effective in the diagnosis and endoscopic treatment of acute LGIB. The diagnostic ability of this procedure seems to be superior for the left colon compared to right colon lesions. This approach enables to suggest bowel preparation and subsequent colonoscopy just to pts with suspected right colon bleeding.

P.16.10 DOUBLE BALLOON ENTEROSCOPY IN DETECTING SMALL BOWEL NEUROENDOCRINE NEOPLASMS (SB-NENS) Rossi R.E.*, Branchi F., Elli L., Conte D., Massironi S. Department of Gastroenterology and Endoscopy, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, and Department of Pathophysiology and Organ Transplantation, Università degli Studi di Milano, milano, Italy Background and aim: Small bowel neuroendocrine neoplasms (SB-NENs) are usually difficult to diagnose, given their nonspecific presentation and poor accessibility of the distal small bowel. The diagnosis of small bowel tumors has been hugely improved with the advent of small bowel endoscopy allowing a direct visualization of the entire small bowel. Data describing the effectiveness of doubleballoon enteroscopy (DBE) in the detection of SB-NENs are scanty,

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due to the low frequency of NENs and the still limited use of DBE in clinical practice. Accordingly, present series was aimed at reporting the experience at a single referral centre for NENs. Material and methods: All consecutive patients with a suspected SB-NEN selected for diagnostic DBE were enrolled at our Institution. Results: Between January 2011 and September 2015, 45 patients with suspected SB-NEN or affected with NEN from unknown primary were referred to our Centre. SB-NENs were suspected on the basis of clinical presentation, elevated neuroendocrine biomarkers and the presence of histologically confirmed neuroendocrine metastases (two patients), positive video capsule endoscopy (VCE) (four patients) or positive nuclear imaging (one patient). After an extensive work-up, six patients (4 M, 2 F, median age 50 years) underwent DBE (three anterograde, two retrograde, one both; median time: 60 min; median insertion 200 cm). DBE was positive in two patients with evidence of an ileal lesion of 1 and 2 cm in diameter, respectively (histologically G1 NEN), these findings being superimposable to those of VCE. Both patients underwent uneventful surgical resection of the SB-NEN. Of the four other patients with negative DBE, two had metastatic NENs of unknown primary, one had primary jejunal NEN revealed by Gallium68-PET and then surgically removed and the last patient resulted a true negative as NEN was not confirmed at long-term follow-up. Overall, in absence of falsely positive results, DBE showed a sensitivity of 33%. No complications were observed during the procedure. Conclusions: In line with data from literature, present series showed that DBE is a safe procedure in the diagnosis of SB-NENs. Further studies are needed to better clarify the diagnostic role of DBE in the neuroendocrine tumor setting and its relationship with other techniques, i.e. VCE and nuclear imaging.

P.16.11 SIMULTANEOUS ONE-PIECE ENDOSCOPIC SUBMUCOSAL DISSECTION FOR TWO POORLY DIFFERENTIATED EARLY GASTRIC CANCER IN ELDERLY PATIENT Alvisi C.*, Rovedatti L., Viganò J., Broglia F., Bardone M., Strada E., Pozzi L., Centenara L., Antonietti M., Natoli S., Lenti M., Dionigi P., Corazza G.R. Fondazione IRCCS Policlinico San Matteo, Pavia, Italy Background and aim: Incidence of early gastric cancer (EGC) is higher in Eastern than in Western countries and endoscopic submucosal dissection (ESD) is actually a feasible treatment since extended indications have been developed. EGC presents with simultaneous multiple lesions in 5.8% to 15% cases and only few Eastern papers describe their simultaneous treatment with ESD. Material and methods: An 81 year-old woman was referred to our unit from another hospital to treat two adjacent but separated mucosal lesions of the antrum greater curvature. According to the Paris Classification lesions were 0-IIa and 0-IIc, about 18mm and 6 mm wide respectively and histological examination of biopsy specimens showed high grade dysplasia and intramucosal adenocarcinoma in the large one and high grade dysplasia in the small one. Endoscopic ultrasound (EUS) described mucosal and only first level submucosal invasion. CT scan was negative. We performed ESD under general anesthesia using Olympus Hook-Knife (Olympus Medical System, Tokyo, Japan). Results: As our video material shows, both adjacent lesions were simultaneously completely removed in one piece. No bleeding or other complications occurred. Every visible vessel was coagulated with hemostatic forceps (Coagrasper Olympus Medical System, Tokyo, Japan) and hemoclips were used for bleeding prophylaxis. Histological examination revealed single specimen of 4.2 x 3.8 cm with 2 lesions: a 0.6cm and a 2cm lesions. Both were poorly

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Abstracts of the 22nd National Congress of Digestive Diseases / Digestive and Liver Disease 48S2 (2016) e67–e231

differentiated adenocarcinoma (PDA) with signet-ring cells (SRC) cancer component (PDA was predominant), no lymphatic or vascular invasion was detected, depth of submucosal invasion was < 500 micron, vertical and horizontal margins were negative and there was no ulceration. Given the patient’s age and histological criteria that met expanded indications for endoscopic resection (ER), after multidisciplinary discussion ESD was considered curative and scheduled a 3-month follow up. Conclusions: EGC diagnosis is more common in Eastern (70%) than in Western (15%) countries and histologically undifferentiated-type is less common than differentiated-type. Only very recently have European guidelines shared the expanded indications for ER of the Japanese guidelines. In conclusion, simultaneous ESD (same day- one piece-same time) for synchronous EGC was a feasible and safe option for our elderly patient. The single procedure for the two EGC reduced hospital stay, avoided patient risks and discomfort, with lower costs compared with separate procedures. To our best knowledge, in Western countries no papers have dealt with “one piece en bloc ESD “ for simultaneous resection of two poorly differentiated adjacent but separated EGC in elderly patient.

P.16.12 CAP-ASSISTED MUCOSECTOMY OF COLORECTAL LESIONS: EXPERIENCE OF 59 CASES BY THE GASTROENTEROLOGY AND ENDOSCOPY UNIT – TRENTO Agugiaro F.*, Franceschini G., Decarli N.L., Pertile R., De Pretis G. Ospedale Santa Chiara, Trento, Italy Background and aim: CAP-assisted endoscopic mucosal resection (C- EMR) is a well codified procedure to treat superficial esophageal and gastric lesions (also reported in the technical file of the device). However the use of these techniques for the resection of colorectal lesions is not regulated. There are few studies on C-EMR for colorectal lesions and few centers perform this type of technique. The main limitation of the use of CAP in colonic lesions is the increased risk of entrapment of the muscle layer in the loop with secondary perforation. The advantages are a better view of the lesion, the opportunity to remove lesions in difficult sites and to obtain deeper histological sample. The Gastroenterology and Endoscopy Unit of Trento performs C-EMR since many years, not only for upper gastrointestinal lesions but also for colorectal lesions. The main aim of the present study was to evaluate usefulness, effectiveness and safety of C-EMR in the treatment of colorectal lesions, compared to piecemeal resection. Material and methods: we retrospective collected all C- EMR for colorectal lesions performed at the Gastroenterology and Endoscopy Unit of Trento, between January 2012 and September 2014. The results were compared with a control group rapresented by the endoscopic piecemeal resection of colorectal lesions larger than 20 mm performed during same period. Results: 59 lesions underwent C-EMR. 41 were lateral spreading tumours (69%) and 18 sessile polyps (31%). Complications were recorded in 4 cases (6.8%): 1 “early” bleeding, 2 “delayed” bleeding and 1 “early” bleeding + perforation. None of them underwent surgery. Post procedure follow up was available in 47 lesions with a median of follow-up of 10 months (range 2-28). Disease recurrence was described in 9 cases (19%). Complications and recurrence rate were compared with the control group (47 piece-meal removed lesions). No differences between the two groups were not statistically significant (complication rate: 6.8% vs 2.1%, p: 0.26; recurrence rate: 19% vs 32.5%; p: 0.07).

Conclusions: The present study shows that the efficacy and safety of C-EMR of colorectal lesions is comparable to the piecemeal resection. Furthermore C-EMR is characterized by a better visualization of the lesions allowing treatment in difficult sites and by deeper histological sections.

P.16.13 THE INCIDENCE OF POST-ERCP PANCREATITIS IS NOT REDUCED IN PATIENTS GIVEN INTRAVENOUS KETOROLAC FOR POSTPROCEDURAL ABDOMINAL PAIN Le Grazie M.*1, Mariani A.1, Di Leo M.1, Maini A.2, Testoni P.A.1 Ospedale San Raffaele, Milano, Italy, 2Ospedale San Secondo, Fidenza, Italy

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Background and aim: Non-steroidal antiinflammatory drugs (NSAIDs) such as indomethacin and diclofenac, administered rectally, are effective in reducing post-ERCP pancreatitis (PEP). This effect seems lost when they are injected intramuscularly or intravenously. The aim is to assess whether intravenous ketorolac given as an analgesic to patients with post-procedural abdominal pain reduces the rate of PEP. Material and methods: We retrospectively evaluated all hospital in-patients who had undergone therapeutic ERCP in a one-year period, comparing the rates of PEP in those who developed postERCP abdominal pain and those who did not. Patients with pain received ketorolac as analgesic NSAID (group A), patients without pain did not (group B). Patients with post-ERCP abdominal pain who were given ketorolac were also compared with those treated with non-NSAIDs because of contraindications. Results: A total of 587 patients underwent ERCP: 277 had postprocedural abdominal pain (47%), 310 had none. Among patients with pain, the rates of PEP were 7.8% for those given ketorolac and 8.5% for those taking non-NSAIDs (p=0.79). Comparing groups A and B, the rates of PEP were not significantly different considering both all the patients (respectively 7.8% and 4.2%, p=0.08) and those at high risk (3.8% and 6%, p=0.6). In multivariate analysis, age was the only factor significantly associated with PEP (p=0.03); ketorolac was not (p=0.16). Conclusions: Intravenous ketorolac to patients with post-ERCP abdominal pain seemed not to reduce the rate of PEP in either the whole group or in patients at high risk for this complication, compared to patients with no post-ERCP pain and no treatment.

P.16.14 BILIARY FULLY COVERED SELF EXPANDABLE METAL STENTS: EXPERIENCE IN A SINGLE CENTER Occhipinti P.*, Orsello M., Armellini E., Ballarè M., Crinò S.F., Montino F., Saettone S., Tari R., Colombo M. Azienda Ospedaliero Universitaria “Maggiore della Carità”, Novara, Italy Background and aim: Fully covered self-expandable metal stents (FCSEMS) have been used for the management of malignant biliary strictures as well as non malignant various biliary conditions including fibrotic distal bile duct stenosis, difficult choledocolithiasis and post-sphincterotomy bleeding. We describe a series of fully covered self expandable metal stents displaced for the treatment of different diseases involving the common bile duct in a single center. Feasibility, short and long term efficacy and adverse events were evaluated. Material and methods: We retrospectively reviewed all the patients treated in the period between January 2014 to june 2015, receiving a fully covered self expandable metal stent as first choice procedure