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Sa1580 Argon Plasma Coagulation Compared With snare Tip Soft Coagulation in an In-Vivo Porcine Model of Endoscopic Mucosal Resection
Abstracts
Sa1580 Argon Plasma Coagulation Compared With snare Tip Soft Coagulation in an In-Vivo Porcine Model of Endoscopic Mucosal Resection Nicholas G. Burgess*1,2, Farzan F. Bahin1,2, Maria Pellise1, Rebecca Sonson1, Rafael Perez-Dye3, Shahrir Kabir4, Vishnu Subramanian5, Hema Mahajan5, Duncan J. Mcleod5, Michael J. Bourke1,2 1 Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; 2Faculty of Medicine, University of Sydney, Sydney, NSW, Australia; 3Department of Animal Care, Westmead Hospital, Sydney, NSW, Australia; 4Department of General Surgery, Westmead Hospital, Sydney, NSW, Australia; 5Department of Tissue Pathology, Westmead Hospital Institute of Clinical Pathology and Medical Research, Sydney, NSW, Australia Introduction: Endoscopic Mucosal Resection (EMR) is now a well-established and effective method for the management of sessile polyps and laterally spreading tumours (LSTs). There are few studies of adjunctive thermal therapies such as argon plasma coagulation (APC) and snare tip soft coagulation (STSC) for the ablation of marginal defect tissue. Small studies examining APC have shown that recurrence may be variably reduced, but criticisms of APC include that it is poorly controllable, that the ablation depth varies, and that it may leave patchy areas of residual mucosa explaining the recurrence that occurs despite treatment. STSC has not been studied in clinical settings to reduce recurrence, but it may have advantages as it is endoscopically easier to control and may provide a more consistent ablative effect. Aims To examine depth of injury and ablation consistency associated with adjunctive thermal therapies for the prevention of marginal recurrence (APC or STSC). Methods: Standardised EMR of porcine mucosa was performed by a single operator. Submucosal injection of a solution of succinylated gelatin (Gelofusine) and indigo carmine was followed by two intersecting 15mm snare resections. Resections were randomised to Erbe VIO 300D EndoCut Q (Effect 3) or Erbe 100C forced coagulation current (25W). The lateral margins of each defect were treated with APC or STSC. Porcine colons were surgically removed at 72 hours post EMR. Pathological resection specimens and porcine colonic defects were assessed by 2 expert gastrointestinal pathologists blinded to the treatment modalities. Study size was calculated based on based on previous porcine studies suggesting a 20% difference in muscularis propria involvement by inflammation or necrosis. Ethical approval was obtained from the Western Sydney Local Health District animal ethics review board. Results: 88 resection defects were created in 12 Landroc-Duroc cross pigs (mean weight 60kg). 2 defects were incorrectly sectioned so were not analysed. 174 tissue sections were assessed comparing APC (87) with STSC (87) ablation. APC treatment did not differ from STSC treatment for deep involvement of the colon wall by acute inflammation (6.9% vs 9.2%, pZ0.58) or chronic inflammatory infiltrate (62.1% vs 64.4%, pZ0.75) although there was a trend towards greater depth of deep necrosis with STSC (4.6% vs 12.6%, pZ0.059). A non-viable necrotic margin was present in 36.8% treated with APC versus 47.1% treated with STSC pZ0.17.. Conclusion: Depth of thermal injury did not differ between APC and STSC in an in-vivo porcine model of EMR however there was a trend toward deeper necrosis with STSC.
Sa1581 Factors Related With Colonic Perforations in Patients Receiving SEMS Insertion for Malignant Colorectal Obstruction Yoo Jin Lee1, Jin Young Yoon2, Jae Hee Cheon2, Soo Jung Park2, Jie-Hyun Kim1, Sung Pil Hong2, Young Hoon Youn1, Tae Il Kim2, Hyojin Park1, Won Ho Kim2, Jae Jun Park*1 1 Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of); 2 Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of) Background/Aim: Although colonic perforation is dreadful complications associated with stenting, data dealing this topic is sparse. The aim of this study was to investigate clinical outcomes of early and late colonic perforation and factors related with its occurrence in patients undergoing self-expanding metal stents (SEMS) for malignant colorectal obstruction. Methods: From April 2004 to May 2011, 490 patients with malignant colorectal obstruction in whom SEMS insertion was attempted were enrolled in Severance and Gangnam Severance hospital. All of the procedure was performed under endoscopic and fluoroscopic guidance. Early perforation that defines as perforation within 2 week was assessed in patients groups both bridge to surgery (nZ165) and palliative aiming stenting (nZ325), meanwhile delayed perforation was analyzed based on the palliative aiming stenting group alone. Results: The technical success rate was 90.4, and the clinical success rate was 80.4%. Perforation occurred in 33 (6.7%) patients. Early perforation that defines as
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perforation within 2 week was occurred in 20 (4.1%) patients. In univariate analysis, location of obstruction (sigmoid colon [6.6%] vs non-sigmoid colon [2.2%], PZ0.014), post stenting ballooning (yes [33.3%] vs no [3.5%], PZ0.004) were significantly associated with early perforation. In subsequent multivariate analysis, both sigmoid colonic location (odd ratio [OR], 4.197, 95% CI, 1.318-13.366)] and post stenting ballooning (OR 17.68, 95% CI 3.600-86.940) were independently associated with occurrence of early perforation. In patients who had experienced colonic perforation after 2 weeks, stent location of left colon was significantly associated with delayed perforation (left colon [6.7%] vs right colon [1.2%], PZ0.022), although it lost its significance in multivariate analysis. Bevacizumab therapy was not associated with increased risk of both early and late perforation. Among 33 patients with perforation, 27 (81.8%) patients received emergency surgery and 5 (15.0%) patients died within 30-day after perforation. Location of the perforation (flexure [27.8%] vs non-flexure [0%], PZ0.049) was significantly associated with 30-day mortality after perforation. Conclusions: This is the first study investigating factors related with colonic perforation for patients with malignant colorectal obstruction in whom SEMS insertion was attempted. Although no factors independently associated with occurrence of delayed perforation, sigmoid colonic location and post stenting ballooning revealed as important factors associated with occurrence of early perforation in these patients.
Sa1582 Use of the Third Eyeâ PanoramicTM Device Expands the View of a Standard Colonoscope Moshe Rubin*1, Leigh Lurie1, Konika P. Bose1, Svetlana Fridyland2, Sang H. Kim1 1 Gastroenterology, New York Presbyterian Queens, Flushing, NY; 2 Nassau University Medical Center, East Meadow, NY Introduction: High adenoma detection rates (ADR) are associated with a decrease in interval colon cancers. Methods to improve ADR include better preparation, timed withdrawal from the cecum, and devices that improve visualization. By adding an additional camera the Third EyeÒ RetroscopeÒ increased the ADR by 23%, detecting lesions hidden behind folds and at flexures. However, its adoption was limited by the need to insert and remove the device from the working channel during colonoscopy. A newer approach is the Third EyeÒ PanoramicTM (TEP, Avantis), a device that has two side-viewing video cameras that combine with the forward view of the colonoscope to provide a panoramic view of over 300o. The TEP clips onto the tip of any standard colonoscope without blocking its channel. Because it complements existing endoscopic technology, there is no need for major capital investment. We report on the successful initial use of the TEP. Methods: The TEP device contains 2 CMOS video chips with left-lateral and right-lateral orientations and adjacent LEDs for illumination. A thin, flexible plastic catheter connects the device to an external processor. The result is 3 distinct but partially overlapping images on a single screen. We recorded ADR, cecal intubation rate, withdrawal time and total procedure time, which included time for lesion removal and intubation of the terminal ileum. Of 34 patients enrolled, 1 was withdrawn for poor bowel prep. The remaining 33 patients (18 M, 15 F) with a mean age of 60 underwent screening, surveillance or diagnostic colonoscopy with the TEP device on a Fujifilm EC530-LS slim colonoscopeÒ. All patients gave informed consent. Results: In all 33 patients the cecum was reached. Mean intubation time was 8.1 minutes, withdrawal time 10.1 minutes and total procedure time was 20 minutes. ADR was 44%. Many diverticula that were viewed en face with the device were not initially seen with the colonoscope. All neoplasms initially detected in the lateral views were readily seen and removed following deflection of the colonoscope’s tip. Use of the device did not affect the colonoscope’s handling characteristics or the quality of its HD image. There were no device failures or adverse events. Several revisions were made to the device during the study. Fasteners to hold the plastic catheter against the colonoscope’s shaft and a mechanism for cleaning lenses proved unnecessary and were eliminated. Moving the side-viewing cameras closer to the tip of the colonscope improved image quality and eliminated a gap between images. Conclusion: In this initial study, the Third Eye Panoramic device was used successfully with a standard colonoscope to provide an extreme wide-angle view that revealed areas behind folds and flexures without affecting handling characteristics or the HD image of the colonoscope.
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB269
Sa1580 Argon Plasma Coagulation Compared With snare Tip Soft Coagulation in an In-Vivo Porcine Model of Endoscopic Mucosal Resection Nicholas G. Burgess*1,2, Farzan F. Bahin1,2, Maria Pellise1, Rebecca Sonson1, Rafael Perez-Dye3, Shahrir Kabir4, Vishnu Subramanian5, Hema Mahajan5, Duncan J. Mcleod5, Michael J. Bourke1,2 1 Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia; 2Faculty of Medicine, University of Sydney, Sydney, NSW, Australia; 3Department of Animal Care, Westmead Hospital, Sydney, NSW, Australia; 4Department of General Surgery, Westmead Hospital, Sydney, NSW, Australia; 5Department of Tissue Pathology, Westmead Hospital Institute of Clinical Pathology and Medical Research, Sydney, NSW, Australia Introduction: Endoscopic Mucosal Resection (EMR) is now a well-established and effective method for the management of sessile polyps and laterally spreading tumours (LSTs). There are few studies of adjunctive thermal therapies such as argon plasma coagulation (APC) and snare tip soft coagulation (STSC) for the ablation of marginal defect tissue. Small studies examining APC have shown that recurrence may be variably reduced, but criticisms of APC include that it is poorly controllable, that the ablation depth varies, and that it may leave patchy areas of residual mucosa explaining the recurrence that occurs despite treatment. STSC has not been studied in clinical settings to reduce recurrence, but it may have advantages as it is endoscopically easier to control and may provide a more consistent ablative effect. Aims To examine depth of injury and ablation consistency associated with adjunctive thermal therapies for the prevention of marginal recurrence (APC or STSC). Methods: Standardised EMR of porcine mucosa was performed by a single operator. Submucosal injection of a solution of succinylated gelatin (Gelofusine) and indigo carmine was followed by two intersecting 15mm snare resections. Resections were randomised to Erbe VIO 300D EndoCut Q (Effect 3) or Erbe 100C forced coagulation current (25W). The lateral margins of each defect were treated with APC or STSC. Porcine colons were surgically removed at 72 hours post EMR. Pathological resection specimens and porcine colonic defects were assessed by 2 expert gastrointestinal pathologists blinded to the treatment modalities. Study size was calculated based on based on previous porcine studies suggesting a 20% difference in muscularis propria involvement by inflammation or necrosis. Ethical approval was obtained from the Western Sydney Local Health District animal ethics review board. Results: 88 resection defects were created in 12 Landroc-Duroc cross pigs (mean weight 60kg). 2 defects were incorrectly sectioned so were not analysed. 174 tissue sections were assessed comparing APC (87) with STSC (87) ablation. APC treatment did not differ from STSC treatment for deep involvement of the colon wall by acute inflammation (6.9% vs 9.2%, pZ0.58) or chronic inflammatory infiltrate (62.1% vs 64.4%, pZ0.75) although there was a trend towards greater depth of deep necrosis with STSC (4.6% vs 12.6%, pZ0.059). A non-viable necrotic margin was present in 36.8% treated with APC versus 47.1% treated with STSC pZ0.17.. Conclusion: Depth of thermal injury did not differ between APC and STSC in an in-vivo porcine model of EMR however there was a trend toward deeper necrosis with STSC.
Sa1581 Factors Related With Colonic Perforations in Patients Receiving SEMS Insertion for Malignant Colorectal Obstruction Yoo Jin Lee1, Jin Young Yoon2, Jae Hee Cheon2, Soo Jung Park2, Jie-Hyun Kim1, Sung Pil Hong2, Young Hoon Youn1, Tae Il Kim2, Hyojin Park1, Won Ho Kim2, Jae Jun Park*1 1 Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of); 2 Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea (the Republic of) Background/Aim: Although colonic perforation is dreadful complications associated with stenting, data dealing this topic is sparse. The aim of this study was to investigate clinical outcomes of early and late colonic perforation and factors related with its occurrence in patients undergoing self-expanding metal stents (SEMS) for malignant colorectal obstruction. Methods: From April 2004 to May 2011, 490 patients with malignant colorectal obstruction in whom SEMS insertion was attempted were enrolled in Severance and Gangnam Severance hospital. All of the procedure was performed under endoscopic and fluoroscopic guidance. Early perforation that defines as perforation within 2 week was assessed in patients groups both bridge to surgery (nZ165) and palliative aiming stenting (nZ325), meanwhile delayed perforation was analyzed based on the palliative aiming stenting group alone. Results: The technical success rate was 90.4, and the clinical success rate was 80.4%. Perforation occurred in 33 (6.7%) patients. Early perforation that defines as
www.giejournal.org
perforation within 2 week was occurred in 20 (4.1%) patients. In univariate analysis, location of obstruction (sigmoid colon [6.6%] vs non-sigmoid colon [2.2%], PZ0.014), post stenting ballooning (yes [33.3%] vs no [3.5%], PZ0.004) were significantly associated with early perforation. In subsequent multivariate analysis, both sigmoid colonic location (odd ratio [OR], 4.197, 95% CI, 1.318-13.366)] and post stenting ballooning (OR 17.68, 95% CI 3.600-86.940) were independently associated with occurrence of early perforation. In patients who had experienced colonic perforation after 2 weeks, stent location of left colon was significantly associated with delayed perforation (left colon [6.7%] vs right colon [1.2%], PZ0.022), although it lost its significance in multivariate analysis. Bevacizumab therapy was not associated with increased risk of both early and late perforation. Among 33 patients with perforation, 27 (81.8%) patients received emergency surgery and 5 (15.0%) patients died within 30-day after perforation. Location of the perforation (flexure [27.8%] vs non-flexure [0%], PZ0.049) was significantly associated with 30-day mortality after perforation. Conclusions: This is the first study investigating factors related with colonic perforation for patients with malignant colorectal obstruction in whom SEMS insertion was attempted. Although no factors independently associated with occurrence of delayed perforation, sigmoid colonic location and post stenting ballooning revealed as important factors associated with occurrence of early perforation in these patients.
Sa1582 Use of the Third Eyeâ PanoramicTM Device Expands the View of a Standard Colonoscope Moshe Rubin*1, Leigh Lurie1, Konika P. Bose1, Svetlana Fridyland2, Sang H. Kim1 1 Gastroenterology, New York Presbyterian Queens, Flushing, NY; 2 Nassau University Medical Center, East Meadow, NY Introduction: High adenoma detection rates (ADR) are associated with a decrease in interval colon cancers. Methods to improve ADR include better preparation, timed withdrawal from the cecum, and devices that improve visualization. By adding an additional camera the Third EyeÒ RetroscopeÒ increased the ADR by 23%, detecting lesions hidden behind folds and at flexures. However, its adoption was limited by the need to insert and remove the device from the working channel during colonoscopy. A newer approach is the Third EyeÒ PanoramicTM (TEP, Avantis), a device that has two side-viewing video cameras that combine with the forward view of the colonoscope to provide a panoramic view of over 300o. The TEP clips onto the tip of any standard colonoscope without blocking its channel. Because it complements existing endoscopic technology, there is no need for major capital investment. We report on the successful initial use of the TEP. Methods: The TEP device contains 2 CMOS video chips with left-lateral and right-lateral orientations and adjacent LEDs for illumination. A thin, flexible plastic catheter connects the device to an external processor. The result is 3 distinct but partially overlapping images on a single screen. We recorded ADR, cecal intubation rate, withdrawal time and total procedure time, which included time for lesion removal and intubation of the terminal ileum. Of 34 patients enrolled, 1 was withdrawn for poor bowel prep. The remaining 33 patients (18 M, 15 F) with a mean age of 60 underwent screening, surveillance or diagnostic colonoscopy with the TEP device on a Fujifilm EC530-LS slim colonoscopeÒ. All patients gave informed consent. Results: In all 33 patients the cecum was reached. Mean intubation time was 8.1 minutes, withdrawal time 10.1 minutes and total procedure time was 20 minutes. ADR was 44%. Many diverticula that were viewed en face with the device were not initially seen with the colonoscope. All neoplasms initially detected in the lateral views were readily seen and removed following deflection of the colonoscope’s tip. Use of the device did not affect the colonoscope’s handling characteristics or the quality of its HD image. There were no device failures or adverse events. Several revisions were made to the device during the study. Fasteners to hold the plastic catheter against the colonoscope’s shaft and a mechanism for cleaning lenses proved unnecessary and were eliminated. Moving the side-viewing cameras closer to the tip of the colonscope improved image quality and eliminated a gap between images. Conclusion: In this initial study, the Third Eye Panoramic device was used successfully with a standard colonoscope to provide an extreme wide-angle view that revealed areas behind folds and flexures without affecting handling characteristics or the HD image of the colonoscope.
Volume 81, No. 5S : 2015 GASTROINTESTINAL ENDOSCOPY AB269