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Item does not contain fulltext BACKGROUND: Etrolizumab is a gut-targeted anti-β7 integrin monoclonal antibody. In a previous phase 2 induction study, etrolizumab significantly improved clinical remission versus placebo in patients with moderately to severely active ulcerative colitis. We aimed to compare the safety and efficacy of etrolizumab with infliximab in patients with moderately to severely active ulcerative colitis. METHODS: We conducted a randomised, double-blind, double-dummy, parallel-group, phase 3 study (GARDENIA) across 114 treatment centres worldwide. We included adults (age 18-80 years) with moderately to severely active ulcerative colitis (Mayo Clinic total score [MCS] of 6-12 with an endoscopic subscore of ≥2, a rectal bleeding subscore of ≥1, and a stool frequency subscore of ≥1) who were naive to tumour necrosis factor inhibitors. Patients were required to have had an established diagnosis of ulcerative colitis for at least 3 months, corroborated by both clinical and endoscopic evidence, and evidence of disease extending at least 20 cm from the anal verge. Participants were randomly assigned (1:1) to receive subcutaneous etrolizumab 105 mg once every 4 weeks or intravenous infliximab 5 mg/kg at 0, 2, and 6 weeks and every 8 weeks thereafter for 52 weeks. Randomisation was stratified by baseline concomitant treatment with corticosteroids, concomitant treatment with immunosuppressants, and baseline disease activity. All participants and study site personnel were masked to treatment assignment. The primary endpoint was the proportion of patients who had both clinical response at week 10 (MCS ≥3-point decrease and ≥30% reduction from baseline, plus ≥1-point decrease in rectal bleeding subscore or absolute rectal bleeding score of 0 or 1) and clinical remission at week 54 (MCS ≤2, with individual subscores ≤1); efficacy was analysed using a modified intention-to-treat population (all randomised patients who received at least one dose of study drug). GARDENIA was designed to show superiority of etrolizumab over infliximab for the primary endpoint. This trial is registered with ClinicalTrials.gov, NCT02136069, and is now closed to recruitment. FINDINGS: Between Dec 24, 2014, and June 23, 2020, 730 patients were screened for eligibility and 397 were enrolled and randomly assigned to etrolizumab (n=199) or infliximab (n=198). 95 (48%) patients in the etrolizumab group and 103 (52%) in the infliximab group completed the study through week 54. At week 54, 37 (18·6%) of 199 patients in the etrolizumab group and 39 (19·7%) of 198 in the infliximab group met the primary endpoint (adjusted treatment difference -0·9% [95% CI -8·7 to 6·8]; p=0·81). The number of patients reporting one or more adverse events was similar between treatment groups (154 [77%] of 199 in the etrolizumab group and 151 [76%] of 198 in the infliximab group); the most common adverse event in both groups was ulcerative colitis (55 [28%] patients in the etrolizumab group and 43 [22%] in the infliximab group). More patients in the etrolizumab group reported serious adverse events (including serious infections) than did those in the infliximab group (32 [16%] vs 20 [10%]); the most common serious adverse event was ulcerative colitis (12 [6%] and 11 [6%]). There was one death during follow-up, in the infliximab group due to a pulmonary embolism, which was not considered to be related to study treatment. INTERPRETATION: To our knowledge, this trial is the first phase 3 maintenance study in moderately to severely active ulcerative colitis to use infliximab as an active comparator. Although the study did not show statistical superiority for the primary endpoint, etrolizumab performed similarly to infliximab from a clinical viewpoint. FUNDING: F Hoffmann-La Roche.

Background and Aims There are no agreed-on endoscopic signs for the diagnosis of villous atrophy (VA) in celiac disease (CD), necessitating biopsy sampling for diagnosis. Here we evaluated the role of near-focus narrow-band imaging (NF-NBI) for the assessment of villous architecture in suspected CD with the development and further validation of a novel NF-NBI classification. Methods Patients with a clinical indication for duodenal biopsy sampling were prospectively recruited. Six paired NF white-light endoscopy (NF-WLE) and NF-NBI images with matched duodenal biopsy sampling including the bulb were obtained from each patient. Histopathology grading used the Marsh-Oberhuber classification. A modified Delphi process was performed on 498 images and video recordings by 3 endoscopists to define NF-NBI classifiers, resulting in a 3-descriptor classification: villous shape, vascularity, and crypt phenotype. Thirteen blinded endoscopists (5 expert, 8 nonexpert) then undertook a short training module on the proposed classification and evaluated paired NF-WLE–NF-NBI images. Results One hundred consecutive patients were enrolled (97 completed the study; 66 women; mean age, 51.2 ± 17.3 years). Thirteen endoscopists evaluated 50 paired NF-WLE and NF-NBI images each (24 biopsy-proven VAs). Interobserver agreement among all validators for the diagnosis of villous morphology using the NF-NBI classification was substantial (κ = .71) and moderate (κ = .46) with NF-WLE. Substantial agreement was observed between all 3 NF-NBI classification descriptors and histology (weighted κ = 0.72-.75) compared with NF-WLE to histology (κ = .34). A higher degree of confidence using NF-NBI was observed when assessing the duodenal bulb. Conclusions We developed and validated a novel NF-NBI classification to reliably diagnose VA in suspected CD. There was utility for expert and nonexpert endoscopists alike, using readily available equipment and requiring minimal training. (Clinical trial registration number: NCT04349904.)

Background Optical diagnosis of colorectal polyps remains challenging. Image-enhancement techniques such as narrow-band imaging and blue-light imaging (BLI) can improve optical diagnosis. We developed and prospectively validated a computer-aided diagnosis system (CADx) using high-definition white-light (HDWL) and BLI images, and compared the system with the optical diagnosis of expert and novice endoscopists. Methods CADx characterized colorectal polyps by exploiting artificial neural networks. Six experts and 13 novices optically diagnosed 60 colorectal polyps based on intuition. After 4 weeks, the same set of images was permuted and optically diagnosed using the BLI Adenoma Serrated International Classification (BASIC). Results CADx had a diagnostic accuracy of 88.3 % using HDWL images and 86.7 % using BLI images. The overall diagnostic accuracy combining HDWL and BLI (multimodal imaging) was 95.0 %, which was significantly higher than that of experts (81.7 %, P = 0.03) and novices (66.7 %, P Conclusion CADx had a significantly higher diagnostic accuracy than experts and novices for the optical diagnosis of colorectal polyps. Multimodal imaging, incorporating both HDWL and BLI, improved the diagnostic accuracy of CADx. BASIC did not increase the diagnostic accuracy of endoscopists compared with intuitive optical diagnosis.

Background and Aims EMR of large (≥2 cm) nonpedunculated colorectal polyps (LNPCPs) is associated with high rates of recurrent/residual adenoma, possibly because of microadenoma left at the margin of resection. Data supporting this mechanism are required. We aimed to determine the incidence of residual microadenoma at the defect margin and base after EMR. Methods We performed a retrospective observational study of patients undergoing EMR of large LNPCPs with the lateral defect margin further resected using the EndoRotor device (Interscope Medical, Inc, Worcester, Mass, USA) after confirming no visible residual adenomatous tissue. Aspects of the defect base were also resected in selected patients. Patients underwent surveillance at 3 to 6 months. Results Resection of the normal defect margin was performed in 41 patients and of aspects of the base in 21 patients. Mean lesion size was 43.0 mm (range, 20-130). Microscopic residual lesion was detected in the margin of apparently normal mucosa in 8 cases (19%). In 7 cases this was an adenoma, and in 1 case a serrated lesion was found at the margin of a resected tubular adenoma. Microscopic residual lesion was detected at the base in 5 of 21 cases. Residual/recurrent adenoma was detected in 2 patients. Neither had residual microadenoma at the lateral margin or base detected after the primary resection. Conclusions Microscopic residual adenoma after wide-field EMR was detected in 19% of cases at the apparently normal defect margin and at the resection base in 5 of 21 cases. This study confirms the presence of residual microadenoma after resection of LNPCPs, providing evidence for the mechanism of recurrence.

Background and Aim: Upper gastrointestinal tumors account for 5% of upper gastrointestinal bleeds. These patients are challenging to treat due to the diffuse nature of the neoplastic bleeding lesions, high rebleeding rates, and significant transfusion requirements. TC-325 (Cook Medical, North Carolina, USA) is a hemostatic powder for gastrointestinal bleeding. The aim of this study was to examine the outcomes of upper gastrointestinal bleeds secondary to tumors treated with Hemospray therapy. Methods: Data were prospectively collected on the use of Hemospray from 17 centers. Hemospray was used during emergency endoscopy for upper gastrointestinal bleeds secondary to tumors at the discretion of the endoscopist as a monotherapy, dual therapy with standard hemostatic techniques, or rescue therapy. Results: One hundred and five patients with upper gastrointestinal bleeds secondary to tumors were recruited. The median Blatchford score at baseline was 10 (interquartile range [IQR], 7–12). The median Rockall score was 8 (IQR, 7–9). Immediate hemostasis was achieved in 102/105 (97%) patients, 15% of patients had a 30-day rebleed, 20% of patients died within 30 days (all-cause mortality). There was a significant improvement in transfusion requirements following treatment (P

Climate change has been described as ‘the biggest global health threat of the 21st century’.1 Medical professionals have a vital role in mitigating the impact of healthcare systems on the environment and protecting vulnerable people through the development of sustainable clinical practices. We have previously written about how gastroenterologists must act now to change our endoscopy practice and make it more aligned with core principles of environmentally sustainable healthcare. But it is clear there is a significant lack of evidence to accurately define the scope of the environmental impact of gastroenterology services, or models of best practice to shape policy and move the field in a new direction. This article aims to provide a framework for us to design and implement quality improvement projects (QIPs) in gastroenterology as a strategy to deliver a more sustainable future in line with the National Health Service (NHS) Net Zero targets.2 Mortimer et al have described the key principles required,3 4 and we aim to apply these to a gastroenterology context and specifically endoscopy services. The value of a healthcare intervention relates to the outcomes delivered against its cost, and the benchmark for cost-effectiveness set by the National Institute for Health and Care Excellence is £20–30 000 per quality-adjusted life year gained.5 However, economists interested in sustainability recognise that costs also need to recognise the social and environmental impact of what is consumed: the so-called ‘triple bottom line’.6 Value can thus be presented using this schematic formula as described by Mortimer et al 3: Value=outcomes for patients and populations/environmental+social+financial impacts. Considered in this way, every healthcare intervention has not only financial implications, but also a social cost on the patient and their family/carers, and environmental implications from resource use and carbon footprint, against which the clinical benefit needs …

ObjectiveThe COVID-19 pandemic has placed increased strain on healthcare systems worldwide with enormous reorganisation undertaken to support ‘COVID-centric’ services. Non-COVID-19 admissions reduced secondary to public health measures to halt viral transmission. We aimed to understand the impact of the response to COVID-19 on the outcomes of upper gastrointestinal (UGI) bleeds.Design/methodsA retrospective observational multicentre study comparing outcomes following endoscopy for UGI bleeds from 24 March 2020 to 20 April 2020 to the corresponding dates in 2019. The primary outcome was in-hospital survival at 30 days with secondary outcomes of major rebleeding within 30 days postprocedure and intervention at the time of endoscopy.Results224 endoscopies for 203 patients with UGI bleeds were included within this study. 19 patients were diagnosed with COVID-19. There was a 44.4% reduction in the number of procedures performed between 2019 and 2020. Endoscopies performed for UGI bleeds in the COVID-19 era were associated with an adjusted reduced 30-day survival (OR 0.25, 95% CI 0.08–0.67). There was no increased risk of major rebleeding or interventions during this era. Patients with COVID-19 did not have reduced survival or increased complication rates.ConclusionEndoscopy for UGI bleeds in the COVID-19 era is associated with reduced survival. No clear cause has been identified but we suspect that this is a secondary effect of the response to the COVID-19 pandemic. Urgent work is required to encourage the public to seek medical help if required and to optimise patient pathways to ensure that the best possible care is provided.

Background Vitamin D deficiency has been implicated in the pathogenesis of inflammatory bowel disease. Emerging literature suggests that optimization of vitamin D levels may be associated with improvements in disease activity and quality of life. We conducted a meta-analysis exploring the effect of vitamin D on serum 25-hydroxyvitamin D (s-25[OH]D) levels, clinical improvement, and biomarkers. Methods MEDLINE, EMBASE, the Cochrane Library, and sources for grey literature were searched from inception until September 2019. The primary outcome was s-25(OH)D mean differences. Heterogeneity was assessed using the χ 2 test and the I2 statistic. Review Manager software v. 5.3 was used. Results Twelve randomized controlled trials (n = 611) and 4 observational studies (n = 359) were included in the meta-analysis. On average, in the randomized controlled trials, vitamin D supplementation increased s-25(OH)D levels by 15.50 ng/mL (95% confidence interval [CI], 11.08-19.92, P ≤ 0.00001, I2 = 90%) and in observational studies they increased by 18.39 ng/mL (95% CI, 8.91-27.88, P = 0.0001, I2 = 82%). Subgroup analyses between vitamin D and placebo groups revealed that vitamin D increased s-25(OH)D by 14.85 ng/mL (95% CI, 9.96-19.73, P ≤ 0.00001, I2 = 90%) and when high doses of vitamin D were compared with low doses, high doses increased s-25(OH)D by 18.27 ng/mL (95% CI, 5.44-31.10, P = 0.005, I2 = 90%). The Harvey Bradshaw Index improved by –1.47 points (95% CI, –2.47 to –0.47, P = 0.004, I2 = 0%) and the high-sensitivity C-reactive protein decreased by –1.58 mg/L (95% CI, –2.95 to –0.21, P = 0.02, I2 = 0%). Conclusions Vitamin D supplementation in patients with IBD and vitamin D deficiency is effective at correcting vitamin D levels and is associated with improvement in clinical and biochemical disease activity scores.

The COVID-19 pandemic is putting unprecedented pressures on healthcare systems globally. Early insights have been made possible by rapid sharing of data from China and Italy. In the UK, we have rapidly mobilised inflammatory bowel disease (IBD) centres in order that preparations can be made to protect our patients and the clinical services they rely on. This is a novel coronavirus; much is unknown as to how it will affect people with IBD. We also lack information about the impact of different immunosuppressive medications. To address this uncertainty, the British Society of Gastroenterology (BSG) COVID-19 IBD Working Group has used the best available data and expert opinion to generate a risk grid that groups patients into highest, moderate and lowest risk categories. This grid allows patients to be instructed to follow the UK government’s advice for shielding, stringent and standard advice regarding social distancing, respectively. Further considerations are given to service provision, medical and surgical therapy, endoscopy, imaging and clinical trials.

Background There is a trend toward organ conservation in the management of rectal tumors. However, there is no consensus on standardized investigations to guide treatment. Objective We report the value of multimodal endoscopic assessment (white light, magnification chromoendoscopy and narrow band imaging, selected colonoscopic ultrasound) for rectal early neoplastic tumors to inform treatment decisions. Design This was a retrospective study. Setting The study was conducted in a tertiary referral unit for interventional endoscopy and early colorectal cancer. Patients A total of 296 patients referred with rectal early neoplastic tumors were assessed using standardized multimodal endoscopic assessment and classified according to risk of harboring invasive cancer. Main outcome measures Sensitivity, specificity, positive and negative predictive values of multimodal endoscopic assessment, and previous biopsy to predict invasive cancer were calculated and treatment outcomes reported. Results After multimodal endoscopic assessment, lesions were classified as invasive cancer, at least deep submucosal invasion (n = 65); invasive cancer, superficial submucosal invasion or high risk of covert cancer (n = 119); or low risk of covert cancer (n = 112). Sensitivity, specificity, positive predictive values, and negative predictive values of multimodal endoscopic assessment for diagnosing invasive cancer, deep submucosal invasion, were 77%, 98%, 93%, and 93%. The combined classification of all lesions with invasive cancer or high risk of covert cancer had a negative predictive value of 96% for invasive cancer on final histopathology. Sensitivity of previous biopsy was 37%. A total of 47 patients underwent radical surgery and 33 transanal endoscopic microsurgery. No patients without invasive cancer were subjected to radical surgery; 222 patients initially underwent endoscopic resection. Of the 203 without deep submucosal invasion, 95% avoided surgery and were free from recurrence at last follow-up. Limitations This was a retrospective study from a tertiary referral unit. Conclusions Standardized multimodal endoscopic assessment guides rational treatment decisions for rectal tumors resulting in organ-conserving treatment for all patients without deep submucosal invasive cancer. See Video Abstract at http://links.lww.com/DCR/B133. LA EVALUACION ENDOSCOPICA MULTIMODAL COMO GUIA DE DECISIONES EN EL TRATAMIENTO DE TUMORES RECTALES NEOPLASICOS PRECOCES: La tendencia actual es la preservacion del organo en el manejo de los tumores de rectao. Sin embargo, no hay consenso sobre las investigaciones estandar para guiar dicho tratamiento.Presentamos los valores de la evaluacion endoscopica multimodal (luz blanca, cromoendoscopia de aumento, imagen de banda estrecha y ecografia colonoscopica seleccionada) para tumores rectales neoplasicos tempranos y asi notificar las decisiones sobre el tratamiento.Estudio retrospectivo.El estudio se realizo en una unidad de referencia terciaria para endoscopia intervencionista y cancer colorrectal temprano.Se evaluaron 296 pacientes referidos con tumores neoplasicos precoces de recto mediante una evaluacion endoscopica multimodal estandarizada y se clasificaron de acuerdo al riesgo de albergar un cancer invasivo.Se calcularon la sensibilidad, la especificidad, los valores predictivos positivos y negativos de la evaluacion endoscopica multimodal y la biopsia previa para predecir el cancer invasivo y se notificaron los resultados para el tratamiento.Despues de la evaluacion endoscopica multimodal, las lesiones se clasificaron como: cancer invasive (al menos invasion submucosa profunda n = 65); cancer invasive (invasion submucosa superficial o alto riesgo de cancer encubierto n = 119) y finalmente aquellos de bajo riesgo de cancer encubierto (n = 112). La sensibilidad, la especificidad, los valores predictivos positivos y negativos de la evaluacion endoscopica multimodal para el diagnostico de cancer invasivo, la invasion submucosa profunda fueron 77%, 98%, 93% y 93% respectivamente. La clasificacion combinada de todas las lesiones con cancer invasivo o de alto riesgo de cancer encubierto tuvo un VPN del 96% para el cancer invasivo en la histopatologia final. La sensibilidad fue de 37% en todas las biopsias previas. 47 pacientes fueron sometidos a cirugia radical, 33 por microcirugia endoscopica transanal. Ningun paciente sin cancer invasivo fue sometido a cirugia radical. Inicialmente, 222 pacientes fueron sometidos a reseccion endoscopica. De los 203 sin invasion submucosa profunda, el 95% evito la cirugia y no tuvieron recurrencia en el ultimo seguimiento.Estudio retrospectivo de una unidad de referencia terciaria.La evaluacion endoscopica multimodal estandarizada guia las decisiones racionales de tratamiento para los tumores rectales que resultan en un tratamiento conservador de organos para todos los pacientes sin cancer invasivo submucoso profundo. Consulte Video Resumen en http://links.lww.com/DCR/B133.

INTRODUCTION: With increasing advances in minimally invasive endoscopic therapies and endoscopic resection techniques for luminal disease, there is an increased risk of post-procedure bleeding. This can contribute to significant burden on patient’s quality of life and health resources when reintervention is required. Hemospray (Cook Medical, North Carolina, USA) is a novel haemostatic powder licensed for gastrointestinal bleeding. The aim of this single-arm, prospective, non-randomised multicentre international study is to look at outcomes in patients with upper gastrointestinal bleeds following elective endoscopic therapy treated with Hemospray to achieve haemostasis. METHODS: Data was prospectively collected on the use of Hemospray from 16 centres (January 2016–November 2019). Hemospray was used during the presence of progressive intraprocedural bleeding post-endoscopic therapy as a monotherapy, dual therapy with standard haemostatic techniques or rescue therapy once standard methods had failed. Haemostasis was defined as the cessation of bleeding within 5 min of the application of Hemospray. Re-bleeding was defined as a sustained drop in haemoglobin (>2 g/l), haematemesis or melaena with haemodynamic instability after the index endoscopy. RESULTS: A total of 73 patients were analysed with bleeding post-endoscopic therapy. The median Blatchford score at baseline was five (interquartile range 0–9). The median Rockall score was six (interquartile range 5–7). Immediate haemostasis following the application of Hemospray was achieved in 73/73 (100%) of patients. Two out of 57 (4%) had a re-bleed post-Hemospray, one was following oesophageal endoscopic mucosal resection and the other post-duodenal endoscopic mucosal resection. Both patients had a repeat endoscopy and therapy within 24 h. Re-bleeding data was missing for 16 patients, and mortality data was missing for 14 patients. There were no adverse events recorded in association with the use of Hemospray. CONCLUSION: Hemospray is safe and effective in achieving immediate haemostasis following uncontrolled and progressive intraprocedural blood loss post-endoscopic therapy, with a low re-bleed rate.

Infection prevention and control (IPC) measures put in place during the first phases of the COVID-19 pandemic were effective in reducing endoscopy-related transmission while allowing recovery of activity. In late 2020 a novel, more infectious, SARS-CoV-2 variant (VOC 202012/01) was associated with a second ’surge' or acceleration phase in the UK. We sought to measure whether pre-existing IPC guidance would be sufficient to prevent transmission in this scenario. Prospective data were collected from eight UK centres for n=2440 procedures. Pre-endoscopy, nine (0.37%) asymptomatic patients were positive for SARS-CoV-2 by nasopharyngeal swab (NPS) testing and their procedures deferred. Post endoscopy, 30 (1.27%) developed symptoms suspicious for COVID-19, with 15 (0.65%) testing positive on NPS. Three (0.12%) cases were attributed to potential transmission from endoscopy attendance. All 15 patients recovered fully requiring only community treatment. Although we report cases potentially transmitted by endoscopy attendance in this latest study, the risk of COVID-19 transmission following outpatient endoscopy remains very low. Thus, IPC measures developed in earlier pandemic phases appear robust, but our data emphasise the need for vigilance and strict adherence to these measures in order to optimally protect both patients and staff. The effects of the COVID-19 pandemic continue to extend beyond direct care of affected patients,1 particularly impacting outpatient diagnostics including GI endoscopy. Considerable concerns remain around the potential impact on detection of, and survival from, significant disease such as cancer.2 3 In mid-2020, a pandemic deceleration phase4 in the UK led to a period of intense ‘restart and recovery’ activity in endoscopy to mitigate the effects of delayed or cancelled procedures. This was supported by professional society guidance on the development of ‘COVID-minimised’ or ‘green’ pathways with NPS testing of patients before their attendance for the procedure.5–7 Activity was limited by the impact on endoscopy staff …

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To determine the efficacy and safety of a 6‐thioguanine nucleotide (6‐TGN) metabolite‐based dosing strategy for maintenance of remission using azathioprine or mercaptopurine in Crohn's disease and ulcerative colitis.

As the incidence of inflammatory bowel disease (IBD) rises and the global population ages, the number of older people living with these conditions will inevitably increase. The challenges posed by comorbid conditions, polypharmacy, the unintended consequences of long-term treatment and the real but often underestimated mismatch between chronological and biological ages underpin management. Significantly, there may be differences in disease characteristics, presentation and management of an older patient with IBD, together with other unique challenges. Importantly, clinical trials often exclude older patients, so treatment decisions are frequently pragmatic, extrapolated from a number of sources of evidence and perhaps primarily dictated by concerns around adverse effects. This review aimed to discuss the epidemiology, clinical features and considerations with management in older patients with IBD.

Background and aim Acute gastrointestinal bleeding carries poor outcomes unless prompt endoscopic hemostasis is achieved. Mortality in these patients remains significant. Hemospray is a novel intervention that creates a mechanical barrier over bleeding sites. We report the largest dataset of patient outcomes after treatment with Hemospray from an international multicenter registry. Patients and methods Prospective data (Jan 2016-May 2018) from 12 centers across Europe were collected. Immediate hemostasis was defined as endoscopic cessation of bleeding within 5 min after application of Hemospray. Rebleeding was defined as subsequent drop in hemoglobin, hematemesis, persistent melena with hemodynamic compromise post-therapy. Results Three hundred and fourteen cases were recruited worldwide (231 males, 83 females). Median pretreatment Blatchford score was 11 (IQR: 8-14) and median complete Rockall score (RS) was 7 (IQR: 6-8) for all patients. Peptic ulcer disease (PUD) was the most common pathology (167/314 = 53%) and Forrest Ib the most common bleed type in PUD (100/167 = 60%). 281 patients (89.5%) achieved immediate hemostasis after successful endoscopic therapy with Hemospray. Rebleeding occurred in 29 (10.3%) of the 281 patients who achieved immediate hemostasis. Seven-day and 30-day all-cause mortality were 11.5% (36/314) and 20.1% (63/314), respectively (lower than the predicted rates as per the RS). Similar hemostasis rates were noted in the Hemospray monotherapy (92.4%), combination therapy (88.7%) and rescue therapy (85.5%) groups. Conclusions These data show high rates of immediate hemostasis overall and in all subgroups. Rebleeding and mortality rates were in keeping/lower than predicted rates.

The latest state of the art technological innovations have led to a palpable progression in endoscopic imaging and may facilitate standardisation of practice. One of the most rapidly evolving modalities is artificial intelligence with recent studies providing real-time diagnoses and encouraging results in the first randomised trials to conventional endoscopic imaging. Advances in functional hypoxia imaging offer novel opportunities to be used to detect neoplasia and the assessment of colitis. Three-dimensional volumetric imaging provides spatial information and has shown promise in the increased detection of small polyps. Studies to date of self-propelling colonoscopes demonstrate an increased caecal intubation rate and possibly offer patients a more comfortable procedure. Further development in robotic technology has introduced ex vivo automated locomotor upper gastrointestinal and small bowel capsule devices. Eye-tracking has the potential to revolutionise endoscopic training through the identification of differences in experts and non-expert endoscopist as trainable parameters. In this review, we discuss the latest innovations of all these technologies and provide perspective into the exciting future of diagnostic luminal endoscopy.

BACKGROUND: People with cystic fibrosis (CF) report a variety of gastrointestinal (GI) symptoms, independent of pancreatic enzyme insufficiency (PEI), reminiscent of other chronic GI disorders. There are currently no accepted or validated assessment tools and neither the range, frequency nor severity of GI symptoms has been systematically described in CF. We present results of a cross-sectional study using established tools and compare them to current measures of quality of life (QOL). METHODS: Consecutive patients attending specialist CF appointments were asked to complete questionnaires including the GI Symptom Rating Scale (GSRS); Irritable Bowel Syndrome Symptom Severity Score (IBS-SSS) and Cystic Fibrosis Questionnaire (CFQ-R). Questionnaire terminology was altered to replace references to ‘IBS’ with ‘GI symptoms’. RESULTS: In total, 107 patients were recruited (mean age, 27.8 ± 9.6 years; 60 female), and 94 (88%) had PEI. Body mass index was 22.1 ± 3.6 kg/m(2), forced expiratory volume in one second was 59 + 27.7% predicted. Fifty-three (49.5%) were p.Phe508del homozygous. Overall 69/107 (65%) reported significant GI symptoms independent of PEI or adherence to pancreatic enzyme replacement therapy (PERT), with the four most frequent being attributable to the lower GI tract: bloating/distension, flatulence, abdominal pain and borborygmi (gurgling). There was no numerical correlation between any CFQ-R domain (particularly Digestion domain) and GSRS or SSS. CONCLUSION: This is the first systematic study measuring GI symptoms in CF using validated GI tools. Symptoms are not related to PERT or genotype and appear to be captured well by the GSRS. Further research will study longitudinal changes with treatment, and therapeutic trials in CF may use these tools to demonstrate a positive impact on ‘non-respiratory’ symptoms and QOL.

Background: The duodenum has become a metabolic treatment target through bariatric surgery learnings and the specific observation that bypassing, excluding or altering duodenal nutrient exposure elicits favourable metabolic changes. Duodenal mucosal resurfacing (DMR) is a novel endoscopic procedure that has been shown to improve glycaemic control in people with type 2 diabetes mellitus (T2D) irrespective of body mass index (BMI) changes. DMR involves catheter-based circumferential mucosal lifting followed by hydrothermal ablation of duodenal mucosa. This multicentre study evaluates safety and feasibility of DMR and its effect on glycaemia at 24 weeks and 12 months. Methods: International multicentre, open-label study. Patients (BMI 24-40) with T2D (HbA1c 59-86 mmol/mol (7.5%-10.0%)) on stable oral glucose-lowering medication underwent DMR. Glucose-lowering medication was kept stable for at least 24 weeks post DMR. During follow-up, HbA1c, fasting plasma glucose (FPG), weight, hepatic transaminases, Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), adverse events (AEs) and treatment satisfaction were determined and analysed using repeated measures analysis of variance with Bonferroni correction. Results: Forty-six patients were included of whom 37 (80%) underwent complete DMR and 36 were finally analysed; in remaining patients, mainly technical issues were observed. Twenty-four patients had at least one AE (52%) related to DMR. Of these, 81% were mild. One SAE and no unanticipated AEs were reported. Twenty-four weeks post DMR (n=36), HbA1c (-10±2 mmol/mol (-0.9%±0.2%), p, SCOPUS: ar.j, info:eu-repo/semantics/published

Almost any colorectal superficial neoplastic lesion can be treated by endoscopic resection (ER) but very little is known about outcomes of ER leaving circumferential or near-circumferential mucosal defects. We report the outcomes of ER leaving ≥ 75% circumferential mucosal defects performed in a western expert centre. Five hundred eighty-seven ERs of large colorectal lesions ≥ 20 mm were grouped according to the extent of the mucosal defect and comparisons made between those with

BACKGROUND & AIMS: Endoscopic and histologic remission are important goals in the treatment of ulcerative colitis (UC). We investigated the correlation of the recently developed Paddington International Virtual ChromoendoScopy ScOre (PICaSSO) and other established endoscopic scores against multiple histological indices and prospectively assessed outcomes. METHODS: In this prospective multicenter international study, inflammatory activity was assessed with high-definition and virtual chromoendoscopy in the rectum and sigmoid using the Mayo Endoscopic Score (MES), UC Endoscopic Index of Severity (UCEIS), and PICaSSO. Targeted biopsies were taken for assessment using Robarts Histological Index (RHI), Nancy Histological index (NHI), ECAP (Extent, Chronicity, Activity, Plus score), Geboes, and Villanacci. Follow-up data were obtained at 6 and 12 months after colonoscopy. RESULTS: A total of 307 patients were recruited. There was strong correlation between PICaSSO and histology scores, significantly superior to correlation coefficients of MES and UCEIS with histology scores. A PICaSSO score of ≤3 detected histologic remission by RHI (≤3 + absence of neutrophils) with area under the receiver operating characteristic curve (AUROC) 0.90 (95% confidence interval [CI] 0.86-0.94) and NHI (≤1) AUROC 0.82 (95% CI 0.77-0.87). The interobserver agreement for PICaSSO was 0.88 (95% CI 0.83-0.92). At 6- and 12-months follow-up, PICaSSO score ≤3 predicted better outcomes than PICaSSO >3 (hazard ratio [HR] 0.19 [0.11-0.33] and 0.22 [0.13-0.34], respectively),} as well as PICaSSO 4-8 (HR 0.25 [0.12-0.53] and 0.22 (0.12-0.39), respectively) and similar to histologic remission. CONCLUSION: In this first real-life multicenter study, the PICaSSO score correlated strongly with multiple histological indices. Furthermore, PICaSSO score predicted specified clinical outcomes at 6 and 12 months, similar to histology. Thus, PICaSSO can be a useful endoscopic tool in the therapeutic management of UC. ispartof: GASTROENTEROLOGY vol:160 issue:5 pages:1558-+ ispartof: location:United States status: published

Introduction Mucosal healing (MH)is an important goal in the treatment of ulcerative colitis (UC). The newly published PICaSSO score characterises subtle mucosal and vascular changes and defines MH. We aimed to validate in real-life the PICaSSO score and assess its ability to predict relapse. Methods Patients with UC were prospectively recruited from 11 international centres. Participating endoscopists experienced in IBD received training on PICaSSO before starting the study. The rectum and sigmoid were examined using iScan 1,2&3 (Pentax, Japan) and inflammatory activity was assessed using Mayo, UCEIS and PICaSSO. Biopsies were taken for histological assessment using Robarts Histological Index (RHI), Nancy, ECAP, Geboes and Villanacci. Follow up data was obtained at 12 months. Results A total of 307 patients were recruited.The interobserver agreement for the PICaSSO score was 0.879 (95% CI 0.826–0.924). The PICaSSO total and PICaSSO mucosal scores strongly correlated with histology scores and was statistically better than MES and UCEIS as show in figure 1. When using a PICaSSO total score of ≤3 the AUROC to predict MH by RHI (≤3 + absence of neutrophils) was 0.90 (95% CI 0.86–0.94) and when we compare the AUROC of Picasso vs Mayo p was =0.06. When using the Nancy score (≤1) the AUROC was 0.816 (95% CI 0.77–0.87). A Kaplan-Meier curve shows a significant favourable survival probability without relapse with a PICASSO score of ≤3 Likelihood ratio test=26.41, p Conclusions This real-life validation study shows the electronic chromoendoscopy score, PICaSSO, can predict accurately histological healing and long-term remission and can be a useful tool in the management of UC.

Objective: Hydrothermal duodenal mucosal resurfacing (DMR) is a safe, outpatient endoscopic procedure. REVITA-2, a double-blind, superiority randomised controlled trial, investigates safety and efficacy of DMR using the single catheter Revita system (Revita DMR (catheter and system)), on glycaemic control and liver fat content in type 2 diabetes (T2D). Design: Eligible patients (haemoglobin A1c (HbA1c) 59-86 mmol/mol, body mass index≥24 and ≤40 kg/m2, fasting insulin >48.6 pmol/L, ≥1 oral antidiabetic medication) enrolled in Europe and Brazil. Primary endpoints were safety, change from baseline in HbA1c at 24 weeks, and liver MRI proton-density fat fraction (MRI-PDFF) at 12 weeks. Results: Overall mITT (DMR n=56; sham n=52), 24 weeks post DMR, median (IQR) HbA1c change was -10.4 (18.6) mmol/mol in DMR group versus -7.1 (16.4) mmol/mol in sham group (p=0.147). In patients with baseline liver MRI-PDFF >5% (DMR n=48; sham n=43), 12-week post-DMR liver-fat change was -5.4 (5.6)% in DMR group versus -2.9 (6.2)% in sham group (p=0.096). Results from prespecified interaction testing and clinical parameter assessment showed heterogeneity between European (DMR n=39; sham n=37) and Brazilian (DMR n=17; sham n=16) populations (p=0.063); therefore, results were stratified by region. In European mITT, 24 weeks post DMR, median (IQR) HbA1c change was -6.6 mmol/mol (17.5 mmol/mol) versus -3.3 mmol/mol (10.9 mmol/mol) post-sham (p=0.033); 12-week post-DMR liver-fat change was -5.4% (6.1%) versus -2.2% (4.3%) post-sham (p=0.035). Brazilian mITT results trended towards DMR benefit in HbA1c, but not liver fat, in context of a large sham effect. In overall PP, patients with high baseline fasting plasma glucose ((FPG)≥10 mmol/L) had significantly greater reductions in HbA1c post-DMR versus sham (p=0.002). Most adverse events were mild and transient. Conclusions: DMR is safe and exerts beneficial disease-modifying metabolic effects in T2D with or without non-alcoholic liver disease, particularly in patients with high FPG. Trial registration number: NCT02879383, SCOPUS: ar.j, info:eu-repo/semantics/published

Introduction The practice of endoscopic submucosal dissection (ESD) for treatment of early gastrointestinal neoplasia has been increasing in the West, however, the uptake has been slow due to a long learning curve and higher complication rate. We aim to analyse UK ESD practice through the development of the first UK national ESD registry. Methods The UK ESD registry was established in 2016 with 4 major tertiary referral centres which was extended to 6 centres by 2019. Data on different parameters ranging from patient demographics to procedural details were collected on a national web based electronic platform and analysed. Results A total of 309 ESDs were performed with a completion rate of 99.2%. Standard ESD was performed in 73.5% whereas hybrid ESD was performed in 26.5% cases. The mean lesion size was 38 mm (range 10 – 130 mm). The overall en bloc resection rate was 86.5%, whereas the R0 resection rate was 72.5%. There were 12 (3.8%) cases with complications ( 7 significant bleeds and 5 perforations). Majority of the colorectal lesions showed a resection histology of LGD (71%) with cancer demonstrated in roughly 10% of the lesions, whereas upper GI lesions showed a higher percentage of atleast SM1 invasive cancer (stomach -61% and oesophagus- 67%). The mean duration between procedure and first follow up endoscopy was 212 days, with visible recurrence occurring in 23 cases (7.4%). Further details comparing standard ESD technique and hybrid ESD have been outlined in table 1. Conclusions We therefore conclude that En bloc resection rates were higher in standard ESD, than in hybrid ESD, however, the latter was involved with fewer complications. Recurrence rates were higher in hybrid ESD compared with standard ESD, however, still lower than for EMR with similar complication rates (specially for colorectal lesions). Although associated with a lower en bloc resection rate and greater recurrence than ESD, hybrid ESD could be an attractive learning step for western endoscopists to be fully competent in standard ESD.

Introduction The gastroduodenal full thickness resection device (FTRD®) is a new device that allows resection of tethered epithelial or subepithelial lesions (SELs) in the stomach and duodenum, but data on outcomes are limited1. Here we present first UK experience of this technique, including technical feasibility, safety and early outcomes. Methods Data on consecutive patients who underwent endoscopic full thickness resection (eFTR) at two UK teaching hospitals in November - December 2019 were analysed. The procedure was undertaken using the endoscope mounted gastroduodenal FTRD®. Main outcome measures were technical success (target lesion resection with FTRD®), total procedural time, specimen size, R0 resection, and adverse events. Need for dilatation to facilitate passage of device past cricopharyngeus or the pylorus was also documented. Results All cases were undertaken under general anaesthetic. It was possible to insert the device to the lesion in all cases; in two, dilatation of the pylorus with a 20 mm through the scope balloon was required to facilitate passage of the device to the duodenum. Technical success and histological diagnosis were achieved in 5/5 (100%) cases. Median total procedural time was 23 minutes (range 18–65). Baseline and outcome data of the cases can be seen in table 1. Two patients were kept for overnight observation and three were discharge on same day as the procedure. One patient reported shivering post procedure, which was thought to be general anaesthesia related, otherwise there were no immediate or delayed complications. Conclusions eFTR of SELs or heavily scarred lesions in the stomach and duodenum is feasible and safe with the gastroduodenal FTRD®. It facilitates acquisition of definite histology aiding diagnosis and R0 resection is possible, providing treatment or avoiding need for ongoing surveillance in selected patients. The device can be challenging to insert and in particular, pre-dilatation of the pylorus to facilitate insertion into the duodenum may be required. References Meier B, Schmidt A, Glaser N, Meining A, Walter B, Wannhoff A, Riecken B, Caca K (2020) Endoscopic full-thickness resection of gastric subepithelial tumors with the gFTRD-system: a prospective pilot study (RESET trial). Surg Endosc 34:853–860

Introduction The association between inflammatory bowel disease (IBD) and autoimmune liver disease (AILD) is well established. Vedolizumab (VDZ) is a gut-specific anti-α4β7 integrin antibody used to treat IBD. VDZ is favoured for AILD patients on additional immunosuppression. This retrospective observational study at a tertiary liver transplant centre aims to review VDZ use in IBD-AILD pre and post liver transplant (LT). Method An electronic database of IBD patients treated with VDZ from November 2014 to February 2020 was used to identify those with AILD. Data on the nature of AILD, response to VDZ, complications or reason for cessation of VDZ was recorded. Results 36 patients with IBD-AILD have been treated with VDZ, with 18 patients receiving ongoing therapy. Demographics are shown in table 1. Of the 18 pre-LT patients, 1 had septic shock from cholangitis at the onset of VDZ therapy, 1 was diagnosed with breast cancer and cholangiocarcinoma a month after VDZ cessation for primary non response. 2 patients underwent LT whilst on VDZ with no post-operative complications. Of the 18 post-LT patients, several complications were seen. There was a single case of: recurrent pharyngitis, Clostridium difficile infection, leukocytoclastic vasculitis, renal cell carcinoma and post-transplant lymphoproliferative disorder (PTLD) in the colon. 5 patients had cholangitis prior to and post VDZ. None of these complications were felt to be related to VDZ and therapy was continued long term in IBD responders. 2 patients have died, 1 due to cholangiocarcinoma and the cause is unknown for the other. 18 patients have stopped VDZ due to: primary non response in 13 cases, cancer in 3 (cholangiocarcinoma, rectal cancer, PTLD), remission in 1 and failure to attend appointments in 1. Conclusion Our experience of VDZ use in IBD-AILD pre and post LT has demonstrated VDZ is a safe treatment option in this cohort. Complications including infections were treatable and patients continued on VDZ. The cessation of VDZ was predominantly due to lack of response and the causal relationship between the cancers and VDZ is not established in this observational study. Prospective multicentre studies would help elucidate further on the use of VDZ in this cohort.

Introduction Per-oral endoscopic myotomy (POEM) is a proven, effective treatment for patients with achalasia, but there are concerns regarding the risk of developing post procedure acid reflux with published studies reporting conflicting results. This study aims to determine the risk of acid reflux and related complications following POEM and influencing factors. Methods This was a single centre, retrospective study. As part of the routine patient pathway, all patients following POEM were offered oesophageal pH testing at 3 months, symptom screening at each follow-up appointment (validated GORD HRQL questionnaire) and surveillance gastroscopy 2–3 years post POEM. Outcomes of interest included abnormal acid exposure time (AET>4.2%), DeMeester Score (>14.72), GORD-HRQL scores and endoscopic findings at surveillance gastroscopy (reflux oesophagitis, Barrett’s oesophagus and malignancy) indicating acid reflux related complications. Results 130 POEM procedures were included in analysis (mean age: 47.4 years, 55 female and median disease duration = 3.0 years). Oesophageal pH results were available for 47 patients; 13/47 (27.7%) had an abnormal AET and 12/47 (25.5%) had a positive DeMeester score. Mean GORD-HRQL symptom scores were lower in patients with abnormal AET (3.1 vs 5.8) but was not statistically significant (p=0.15). Comparing patients with abnormal and normal AET there was no significant difference for history of prior therapy (p=0.79), prior myotomy (p=0.80), disease duration (p=0.49) and total myotomy length (p=0.14). 4/20 (20.0%) of surveillance gastroscopies demonstrated evidence of reflux oesophagitis; there were no cases of Barrett’s oesophagus or malignancy. Conclusions This study demonstrated a prevalence of 27.7% for abnormal acid exposure following POEM based on pH studies, this is at the lower limit of published research. No factors influencing the development of abnormal AET were identified. Symptom scores were lower in patients with abnormal AET but not statistically significant. Although, it is reassuring that acid reflux may be lower following POEM than previously thought, clinicians must remain vigilant and continue to offer routine pH testing and surveillance gastroscopy. Especially, as symptoms of acid reflux are a poor correlate with abnormal AET. Long-term surveillance should continue in this patient group to truly determine the long-term risks of post POEM acid reflux and associated sequalae.

Background The COVID-19 pandemic has placed increased strain on healthcare systems worldwide with enormous reorganisation undertaken to support ‘COVID-centric’ services. Non-COVID-19 admissions have been shown to have reduced due to public health measures to halt viral transmission. We aimed to understand the impact of the response to the COVID-19 pandemic on the outcomes of upper gastrointestinal bleeds (UGI). Methods A pan-London retrospective observational multi-centre study comparing outcomes following endoscopy for UGI bleeds from 24th March 2020 to 20th April 2020 to the corresponding dates in 2019. Primary outcome was in-hospital survival at 30 days with secondary outcomes of major re-bleeding within 30 days post-procedure and intervention at time of endoscopy. Results 224 endoscopies for 203 patients with UGI bleeds were included within this study. 19 patients were diagnosed with COVID-19. There was a 44.4% reduction in the number of procedures performed between 2019 and 2020. Endoscopies performed for UGI bleeds in the COVID-19 era were associated with an adjusted reduced 30-day survival (OR 0.25, 95% CI 0.08–0.67) (figure 1). There was no increased risk of major re-bleeding or interventions during this era. Patients with COVID-19 did not have adjusted reduced survival or adjusted increased complication rates. Conclusions Endoscopy for UGI bleeds in the COVID-19 era is associated with reduced survival. No clear cause has been identified but we suspect this is a secondary effect of the response to the COVID-19 pandemic. Urgent work is required to encourage the public to seek medical help if required and to optimise patient pathways to ensure that the best possible patient care is provided.

Background and study aims The contribution of artificial intelligence (AI) to endoscopy is rapidly expanding. Accurate labelling of source data (video frames) remains the rate-limiting step for such projects and is a painstaking, cost-inefficient, time-consuming process. A novel software platform, Cord Vision (CdV) allows automated annotation based on “embedded intelligence.” The user manually labels a representative proportion of frames in a section of video (typically 5 %), to create ‘micro-modelsʼ which allow accurate propagation of the label throughout the remaining video frames. This could drastically reduce the time required for annotation. Methods We conducted a comparative study with an open-source labelling platform (CVAT) to determine speed and accuracy of labelling. Results Across 5 users, CdV resulted in a significant increase in labelling performance (P Conclusions This advance represents a valuable first step in AI-image analysis projects.

The COVID-19 pandemic has severely curtailed the practice of endoscopy (as an exemplar for outpatient diagnostic procedures) worldwide. Restart and recovery processes will be influenced by the need to protect patients and staff from disease transmission, but data on the risk of COVID-19 transmission after an endoscopy are sparse. This is of particular importance in later pandemic phases when the risk of harm from delayed or missed significant diagnoses is likely to far outweigh the risk of infection. The British Society of Gastroenterology guidance for restarting endoscopy included the stratification of diagnostic procedures according to aerosol generation or assessment of infectious risk as well as pragmatic guidance on the use of personal protective equipment (PPE). We sought to document the risk of COVID-19 transmission after endoscopy in this ‘COVID-minimised’ environment. Prospective data were collected from 18 UK centres for n=6208 procedures. Pre-endoscopy, 3 of 2611 (0.11%; 95% CI 0.00%–0.33%) asymptomatic patients tested positive for SARS-CoV-2 on nasopharyngeal swab. Based on follow-up telephone symptom screening of patients at 7 and 14 days, no cases of COVID-19 were detected by any centre after endoscopy in either patients or staff. Although these data cannot determine the relative contribution of each component of a COVID-minimised pathway, they provide clear support for such an approach. The rational use of PPE and infection control policies should be continued and will aid in planning for outpatient diagnostics in the COVID-19 recovery phase. The COVID-19 pandemic has had an extraordinary impact on the delivery of GI endoscopy, with an initial reduction to 12% of prepandemic levels in the UK.1 In the deceleration and early recovery phases (up to end July 2020), this had risen to 42% of repandemic levels.2 Recovery has been influenced by multiple factors including availability of staff, restrictions caused by longer room cleansing, physical …

MessageThe COVID-19 pandemic has severely curtailed the practice of endoscopy (as an exemplar for outpatient diagnostic procedures) worldwide. Restart and recovery processes will be influenced by the need to protect patients and staff from disease transmission, but data on the risk of COVID-19 transmission after endoscopy are sparse. This is of particular importance in later pandemic phases when the risk of harm from delayed or missed significant diagnoses is likely to far outweigh the risk of infection. The British Society of Gastroenterology (BSG) guidance for restarting endoscopy included stratification of diagnostic procedures according to aerosol generation or assessment of infectious risk as well as pragmatic guidance on the use of personal protective equipment (PPE). We sought to document the risk of COVID-19 transmission after endoscopy in this “COVID-minimised” environment. Prospective data were collected from 18 UK centres for n=6208 procedures. Pre-endoscopy, 3/2611 (0.11% [95% CI: 0.00-0.33%]) asymptomatic patients tested positive for SARS-CoV-2 on nasopharyngeal swab. Based on follow-up telephone symptom screening of patients at 7 and 14 days, no cases of COVID-19 were detected by any centre after endoscopy in either patients or staff. While these data cannot determine the relative contribution of each component of a COVID-minimised pathway, they provide clear support for such an approach. The rational use of PPE and infection control policies should be continued and will aid planning for outpatient diagnostics in the COVID-19 recovery phase.

Artificial intelligence is a strong focus of interest for global health development. Diagnostic endoscopy is an attractive substrate for artificial intelligence with a real potential to improve patient care through standardisation of endoscopic diagnosis and to serve as an adjunct to enhanced imaging diagnosis. The possibility to amass large data to refine algorithms makes adoption of artificial intelligence into global practice a potential reality. Initial studies in luminal endoscopy involve machine learning and are retrospective. Improvement in diagnostic performance is appreciable through the adoption of deep learning. Research foci in the upper gastrointestinal tract include the diagnosis of neoplasia, including Barrett’s, squamous cell and gastric where prospective and real-time artificial intelligence studies have been completed demonstrating a benefit of artificial intelligence–augmented endoscopy. Deep learning applied to small bowel capsule endoscopy also appears to enhance pathology detection and reduce capsule reading time. Prospective evaluation including the first randomised trial has been performed in the colon, demonstrating improved polyp and adenoma detection rates; however, these appear to be relevant to small polyps. There are potential additional roles of artificial intelligence relevant to improving the quality of endoscopic examinations, training and triaging of referrals. Further large-scale, multicentre and cross-platform validation studies are required for the robust incorporation of artificial intelligence–augmented diagnostic luminal endoscopy into our routine clinical practice.

The COVID-19 pandemic has placed extraordinary demands on healthcare services worldwide. Strategic planning for acute COVID-19 care has, during the peak phase of the pandemic, rightly overshadowed the provision of diagnostic services, which have been further restricted by the need to minimise viral transmission to reduce the attendant risks to patients and staff. The risk is compounded by the asymptomatic phase of COVID-19 infection1 and is particularly important in relation to GI endoscopy, given the aerosol-generating nature of many endoscopic procedures.2–4 The British Society of Gastroenterology released early guidance to assist local teams in prioritising certain indications for GI endoscopy, even during the tight restrictions demanded by the peak phase of the pandemic.2 Other endoscopy societies or expert groups have also published guidance on the management of GI endoscopy during the pandemic, and these are summarised elsewhere.5 In the deceleration phase of the pandemic, as defined by a sustained fall in new infectious cases over 14 consecutive days,6 7 healthcare systems will rightly look to implement measures to safely restart activity. Endoscopy capacity should be restored as far as possible while ensuring mechanisms are in place to reassure and protect patients and staff from avoidable risk. There is significant risk in continued delay of diagnostic services. For GI endoscopy, this relates to cancers as well as other time-critical conditions such as IBD. While COVID-19 has tragically accounted for over 200 000 reported deaths by the end of April 2020,8 there were around 18 million cases of cancer worldwide in 2018 and 10 million cancer deaths, with colorectal and gastric cancer accounting for 17% of deaths.9 It has been conservatively estimated that delays to cancer diagnoses and treatment could be responsible for nearly 7000 additional deaths in England and over 30 000 deaths in the USA.10 It …

Background: The COVID-19 pandemic has placed increased strain on healthcare systems worldwide with enormous reorganisation undertaken to support ‘COVID-centric’ services. Non-COVID-19 admissions have reduced secondary to public health measures including nationwide lockdowns to halt transmission of the virus. We examined the impact of COVID-19 on the endoscopic management of upper gastrointestinal (GI) bleeds in London, UK. Methods: A retrospective observational multi-centre study comparing outcomes following the endoscopic management of upper GI bleeds from 24th March 2020 to 20th April 2020 to the corresponding dates in 2019. Findings: There was a 44.4% reduction in the number of procedures performed between 2019 and 2020. Endoscopies performed for upper GI bleeds in the COVID-19 era were associated with a reduced 30-day survival and this remained significant following adjustment for other risk factors (OR 0.25, 95% CI 0.08-0.67). However, there was no increased risk of major re-bleeding or therapeutic intervention during this time period. Patients with COVID-19 did not have reduced survival or increased complication rates. Interpretation: Reduced survival following endoscopy for upper GI bleeds in the COVID-19 era is likely a secondary effect of the COVID-19 pandemic. Urgent work is required to encourage the public to seek medical help if required and to optimise patient pathways to ensure the best possible care is provided. Funding: None Declaration of Interests: None. Ethics Approval Statement: Local departmental approval was gained for each participating site.

BACKGROUND Endoscopic resection of large colorectal lesions is well reported and is the first line of treatment for all noninvasive colorectal neoplasms in many centers, but little is known about the outcomes of endoscopic resection of truly massive colorectal lesions ≥8 cm. OBJECTIVE We report on the outcomes of endoscopic resection for massive (≥8 cm) colorectal adenomas and compare the outcomes with resection of large (2.0-7.9 cm) lesions. DESIGN This was a retrospective study. SETTINGS The study was conducted in a tertiary referral unit for interventional endoscopy. PATIENTS A total of 435 endoscopic resections of large colorectal polyps (≥2 cm) were included, of which 96 were ≥8 cm. MAIN OUTCOME MEASURES Outcomes included initial successful resection, complications, recurrence, surgery, and hospital admission. RESULTS Endoscopic resection was successful for 91 of 96 massive lesions (≥8 cm). Mean size was 10.1 cm (range, 8-16 cm). A total of 75% had previous attempts at resection or heavy manipulation before referral. Thirty two were resected using endoscopic submucosal dissection or hybrid endoscopic submucosal dissection and the rest using piecemeal endoscopic mucosal resection. No patients required surgery for a perforation. Five patients had postprocedural bleeding. There were 25 recurrences: 2 were treated with transanal endoscopic microsurgery, 2 with right hemicolectomy, and the rest with endoscopic resection. Compared with patients with large lesions, more patients with massive adenomas had complications (19.8% versus 3.3%), required admission (39.6% versus 11.0%), developed recurrence (30.8% versus 9.9%), or required surgery for recurrence (5.0% versus 0.8%). LIMITATIONS This was a retrospective study. CONCLUSIONS Endoscopic resection of massive colorectal adenomas ≥8 cm is achievable with few significant complications, and the majority of patients avoid surgery. Systematic assessment is required to appropriately select patients for endoscopic resection, which should be performed in specialist units. See Video Abstract at http://links.lww.com/DCR/A653.

The significantly increased risk of colorectal cancer (CRC) in longstanding colonic inflammatory bowel disease (IBD) justifies the need for endoscopic surveillance. Unlike sporadic CRC, IBD-related CRC does not always follow the predictable sequence of low-grade to high-grade dysplasia and finally to invasive carcinoma, probably because the genetic events shared by both diseases occur in different sequences and frequencies. Surveillance is recommended for patients who have had colonic disease for at least 8-10 years either annually, every 3 years or every 5 years with the interval dependant on the presence of additional risk factors. Currently, the recommended endoscopic strategy is high-definition chromoendoscopy with targeted biopsies, although the associated lengthier procedure time and need for experienced endoscopists has limited its uniform uptake in daily practice. There is no clear consensus on the management of dysplasia, which continues to be a challenging area particularly when endoscopically invisible. Management options include complete resection (and/or referral to a tertiary centre), close surveillance or proctocolectomy. Technical advances in endoscopic imaging such as confocal laser endomicroscopy, show exciting potential in increasing dysplasia detection rates but are still far from being routinely used in clinical practice.

We read with interest the paper by Bang et al on the equivalence of single-use duodenoscopes compared with conventional reusable duodenoscopes to prevent transmissible infections.1 We congratulate the authors for their study demonstrating the economic, technical and safety equivalence of single-use duodenoscopes to conventional reusable duodenoscopes for endoscopic retrograde cholangiopancreatography (ERCP). The drive toward single-use endoscopes was generated by the incidence of duodenoscope-related infections in the USA, prompting the Food and Drug Administration in 2019 to recommend that healthcare providers and manufacturers transition to disposable components in duodenoscopes to reduce transmissible infections. A systematic review and meta-analysis of the rate and impact of duodenoscope infection involved 15 studies with over 13 000 duodenoscope analysis and found a 15.25% rate of contamination from preprocessed patient-ready duodenoscopes.2 It must be stated that the risk …

ObjectiveThe aims of this study were to describe community antibiotic prescribing patterns in individuals hospitalised with COVID-19, and to determine the association between experiencing diarrhoea, stratified by preadmission exposure to antibiotics, and mortality risk in this cohort.Design/methodsRetrospective study of the index presentations of 1153 adult patients with COVID-19, admitted between 1 March 2020 and 29 June 2020 in a South London NHS Trust. Data on patients’ medical history (presence of diarrhoea, antibiotic use in the previous 14 days, comorbidities); demographics (age, ethnicity, and body mass index); and blood test results were extracted. Time to event modelling was used to determine the risk of mortality for patients with diarrhoea and/or exposure to antibiotics.Results19.2% of the cohort reported diarrhoea on presentation; these patients tended to be younger, and were less likely to have recent exposure to antibiotics (unadjusted OR 0.64, 95% CI 0.42 to 0.97). 19.1% of the cohort had a course of antibiotics in the 2 weeks preceding admission; this was associated with dementia (unadjusted OR 2.92, 95% CI 1.14 to 7.49). After adjusting for confounders, neither diarrhoea nor recent antibiotic exposure was associated with increased mortality risk. However, the absence of diarrhoea in the presence of recent antibiotic exposure was associated with a 30% increased risk of mortality.ConclusionCommunity antibiotic use in patients with COVID-19, prior to hospitalisation, is relatively common, and absence of diarrhoea in antibiotic-exposed patients may be associated with increased risk of mortality. However, it is unclear whether this represents a causal physiological relationship or residual confounding.

Endoscopic submucosal dissection (ESD) enables en bloc resection of large complex colorectal superficial neoplastic lesions, resulting in very low rates of local recurrence, high-quality pathologic specimens for accurate histopathologic diagnosis and potentially curative treatment of early adenocarcinoma without resorting to major surgical resection. The safety and efficacy of the technique, which was pioneered in the upper gastrointestinal tract, has been established by the consistently impressive outcomes from expert centers in Japan and some other eastern countries. However, ESD is challenging to perform in the colorectum and there is a significant risk of complications, particularly in the early stages of the learning curve. Early studies from western centers raised concerns about the high complication rates, and the impressive results from Japanese centers were not replicated. As a result, many western endoscopists are skeptical about the role of ESD and few centers have incorporated the technique into their practice. Nevertheless, although the distribution of expertise, referral centers and modes of practice may differ in Japan and western countries, ESD has an important role and can be safely and effectively incorporated into western practice. Key to achieving this is meticulous lesion assessment and selection, appropriate referral to centers with the necessary expertise and experience and application of the appropriate technique individualized to the patient. This review discusses the advantages, risks and benefits of ESD to treat colorectal lesions and the importance of preprocedure lesion assessment and in vivo diagnosis and outlines a pragmatic rationale for appropriate lesion selection as well as the patient, technical and institutional factors that should be considered.