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Background and Aims: Pre-cut techniques, the most commonly described being needle knife papillotomy (NK), have been used to facilitate biliary access in failed standard biliary cannulation (BC). Transpancreatic septotomy (TS) is a pre-cut technique with limited outcome data. We aim to assess the outcomes of wire assisted transpancreatic septotomy (WTS) as the primary pre-cut technique after initial failed attempted BC and to compare these with outcomes of primary NK. Methods: We retrospectively reviewed all endoscopic retrograde cholangiopancreatographies (ERCPs) performed by endoscopists who performed WTS over a 3-year period. We selected cases where WTS and/or NK were performed, and these cases were reviewed to assess for procedure related complications and BC success. Results: During the study period 1336 ERCPs were performed. WTS was performed in 53 cases. In seven cases WTS and NK were performed sequentially (resulting in immediate cannulation in all these cases). Immediate BC was achieved on first attempt in 36 (68%) WTS cases and in a further 14 cases on a repeat attempt (cumulative BC rate 94%). During the same period 66 (5%) patients underwent primary NK. In these cases initial cannulation was achieved in 50 (76%) cases and cannulation on repeat attempt in six cases (cumulative success rate 85%). Complications occurred in three WTS patients (5.6%) and seven NK patients (10.6%). The differences were not statistically significant. Conclusions: Wire assisted transpancreatic septotomy is a safe and effective alternative technique to traditional NK in patients who have failed standard BC techniques. It also allows other pre-cut techniques such as NK to be used should initial WTS be unsuccessful.

Background and Aims: Endoscopic resection of large colorectal neoplasms is increasingly being used as an alternative to surgery. However data on failure rates, safety and long-term outcomes remain limited. The aim of the study was to report short- and long-term outcomes from endoscopic resection of large colorectal neoplasms from a single centre and use a model to predict mortality had surgery been performed. Methods: Consecutive patients referred for endoscopic resection of large (≥ 20 mm) colorectal neoplasms from January 2001 to February 2008 were included. Resection details were recorded in a prospectively maintained database. Data was collected on 30-day complication rates, and follow-up colonoscopy findings. The Colorectal-POSSUM score was used to estimate mortality from open surgery. Results: There were 154 large neoplasms in 140 patients. Mean age was 68 years (range 22–94). Mean neoplasm size was 26 mm (range 20–80 mm, 24 ≥ 40 mm). Complete endoscopic removal was achieved in 95% of cases. Twenty patients were referred for surgery (14%). In the endoscopy group, there were no deaths within 30 days. Twelve patients had a complication including two perforations. Endoscopic follow-up data was available in 90% of cases and five patients (4%) were found to have residual adenoma that was treated endoscopically with subsequent clearance. If surgery had been performed, the mean predicted mortality was 2.2% (range 0.5–10%). There were two deaths (10%) in patients who underwent elective surgery within 30 days. Conclusion: Endoscopic resection of large colorectal neoplasms is safe and effective even for very large benign neoplasms. When the lesion is endoscopically resectable this should be the preferred treatment.

Endoscopic mucosal resection (EMR) is effective for large laterally spreading flat and sessile lesions (LSLs). Sessile serrated adenomas/polyps (SSA/Ps) are linked to the relative failure of colonoscopy to prevent proximal colorectal cancer. We aimed to examine the technical success, adverse events and recurrence following EMR for large SSA/Ps in comparison with large conventional adenomas.Over 74 months till August 2014, prospective multicentre data of LSLs ≥20 mm were analysed. A standardised dye-based conventional EMR technique followed by scheduled surveillance colonoscopy was used.From a total of 2000 lesions, 323 SSA/Ps in 246 patients and 1527 adenomas in 1425 patients were included for analysis. Technical success for EMR was superior in SSA/Ps compared with adenomas (99.1% vs 94.5%, p0.001). Significant bleeding and perforation were similar in both cohorts. The cumulative recurrence rates for adenomas after 6, 12, 18 and 24 months were 16.1%, 20.4%, 23.4% and 28.4%, respectively. For SSA/Ps, they were 6.3% at 6 months and 7.0% from 12 months onwards (p0.001). Following multivariable adjustment, the HR of recurrence for adenomas versus SSA/Ps was 1.7 (95% CI 0.9 to 3.0, p=0.097). Subgroup analysis by lesion size revealed an eightfold increased risk of recurrence for 20-25 mm adenomas versus SSA/Ps, but no significantly different risk between lesion types in larger lesion groups.Recurrence after EMR of 20-25 mm LSLs is significantly less frequent in SSA/Ps compared with adenomatous lesions. SSA/Ps can be more effectively removed than adenomatous LSLs with equivalent safety. Ensuring complete initial resection is imperative for avoiding recurrence.ClinicalTrials.gov NCT01368289.

Background and Aims: In patients undergoing colonoscopy for diarrhea, when the examination is normal, the role of routine mucosal biopsy remains controversial, particularly in the open-access setting. It is uncertain whether routine ileoscopy adds anything to colonoscopy alone. We aimed to assess the yield of mucosal biopsy and ileoscopy in patients with diarrhea. Methods: We retrospectively reviewed all colonoscopies performed for diarrhea over a 9-year period in a tertiary referral center with an open-access service. We then selected cases where the examination was normal and biopsies were performed. The histopathology reports of these selected cases were then reviewed. Results There were 1131 cases identified. The mucosal examination was normal in 465 cases (41%); 362 of these had colonic biopsies performed. Histology was normal in 316 cases (87%) and was non-specific in 28 cases (8%). Significant histopathology was present in 18 cases (5%) with a significantly higher prevalence of microscopic colitis in patients above 60 years old. Ileoscopy was performed in 508 cases and was abnormal in 26 cases (5%). The abnormality on ileoscopy was the sole abnormality in 13 cases (3%). Conclusions Routine colonic mucosal biopsy and ileoscopy each identify significant additional pathology in 5% of cases when investigating patients with diarrhea, and are recommended as routine practice in this setting. We found ileal biopsy unhelpful when ileoscopy was normal. © 2002 Blackwell Science Asia Pty Ltd

Background & Aims Among patients with large colorectal sessile polyps or laterally spreading lesions, it is important to identify those at risk for submucosal invasive cancer (SMIC). Lesions with overt endoscopic evidence of SMIC are referred for surgery, although those without these features might still contain SMIC that is not visible on endoscopic inspection (covert SMIC). Lesions with a high covert SMIC risk might be better suited for endoscopic submucosal dissection than for endoscopic mucosal resection (EMR). We analyzed a group of patients with large colon lesions to identify factors associated with SMIC, and examined lesions without overt endoscopic high-risk signs to determine factors associated with covert SMIC. Methods We performed a prospective cohort study of consecutive patients referred for EMR of large sessile or flat colorectal polyps or laterally spreading lesions (≥20 mm) at academic hospitals in Australia from September 2008 through September 2016. We collected data on patient and lesion characteristics, outcomes of procedures, and histology findings. We excluded serrated lesions from the analysis of covert SMIC due to their distinct phenotype and biologic features. Results We analyzed 2277 lesions (mean size, 36.9 mm) from 2106 patients (mean age, 67.7 years; 53.2% male). SMIC was evident in 171 lesions (7.6%). Factors associated with SMIC included Kudo pit pattern V, a depressed component (0–IIc), rectosigmoid location, 0–Is or 0–IIa+Is Paris classification, non-granular surface morphology, and increasing size. After exclusion of lesions that were obviously SMIC or serrated, factors associated with covert SMIC were rectosigmoid location (odds ratio, 1.87; P = .01), combined Paris classification, surface morphology (odds ratios, 3.96−22.5), and increasing size (odds ratio, 1.16/10 mm; P = .012). Conclusions In a prospective study of 2106 patients who underwent EMR for large sessile or flat colorectal polyps or laterally spreading lesions, we associated rectosigmoid location, combined Paris classification and surface morphology, and increasing size with increased risk for covert malignancy. Rectosigmoid 0–Is and 0–IIa+Is non-granular lesions have a high risk for malignancy, whereas proximally located 0–Is or 0–IIa granular lesions have a low risk. These findings can be used to inform decisions on which patients should undergo endoscopic submucosal dissection, EMR, or surgery. ClinicalTrials.gov, Number: NCT02000141.

Background and Aims EMR is the primary treatment of large laterally spreading lesions (LSLs) in the colon. Residual or recurrent adenoma (RRA) is a major limitation. We aimed to identify a robust method to stratify the risk of RRA. Methods Prospective multicenter data on consecutive LSLs ≥20 mm removed by piecemeal EMR from 8 Australian tertiary-care centers were included (September 2008 until May 2016). A logistic regression model for endoscopically determined recurrence (EDR) was created on a randomly selected half of the cohort to yield the Sydney EMR recurrence tool (SERT), a 4-point score to stratify the incidence of RRA based on characteristics of the index EMR. SERT was validated on the remainder of the cohort. Results Analysis was performed on 1178 lesions that underwent first surveillance colonoscopy (SC1) (median 4.9 months, interquartile range [IQR] 4.9-6.2). EDR was detected in 228 of 1178 (19.4%) patients. LSL size ≥40 mm (odds ratio [OR] 2.47; P P = .024), and high-grade dysplasia (OR 1.72; P = .029) were identified as independent predictors of EDR and allocated scores of 2, 1, and 1, respectively to create SERT. Lesions with SERT scores of 0 (SERT = 0) had a negative predictive value of 91.3% for RRA at SC1, and SERT was shown to stratify RRA to specific follow-up intervals by using Kaplan Meier curves (log-rank P Conclusions Guidelines recommend SC1 within 6 months of EMR. SERT accurately stratifies the incidence of RRA after EMR. SERT = 0 lesions could safely undergo first surveillance at 18 months, whereas lesions with SERT scores between 1 and 4 (SERT 1-4) require surveillance at 6 and 18 months. (Clinical trial registration number: NCT01368289.)

The serrated neoplasia pathway accounts for up to 30% of all sporadic colorectal cancers (CRCs). Sessile serrated adenomas/polyps (SSA/Ps) with cytological dysplasia (SSA/P-D) are a high-risk serrated CRC precursor with little existing data. We aimed to describe the clinical and endoscopic predictors of SSA/P-D and high grade dysplasia (HGD) or cancer.Prospective multicentre data of SSA/Ps ≥20 mm referred for treatment by endoscopic mucosal resection (September 2008-July 2013) were analysed. Imaging and lesion assessment was standardised. Histological findings were correlated with clinical and endoscopic findings.268 SSA/Ps were found in 207/1546 patients (13.4%). SSA/P-D comprised 32.4% of SSA/Ps ≥20 mm. Cancer occurred in 3.9%. On multivariable analysis, SSA/P-D was associated with increasing age (OR=1.69 per decade; 95% CI (1.19 to 2.40), p0.004) and increasing lesion size (OR=1.90 per 10 mm; 95% CI (1.30 to 2.78), p0.001), an 'adenomatous' pit pattern (Kudo III, IV or V) (OR=3.98; 95% CI (1.94 to 8.15), p0.001) and any 0-Is component within a SSA/P (OR=3.10; 95% CI (1.19 to 8.12) p0.021). Conventional type dysplasia was more likely to exhibit an adenomatous pit pattern than serrated dysplasia. HGD or cancer was present in 7.2% and on multivariable analysis, was associated with increasing age (OR=2.0 per decade; 95% CI 1.13 to 3.56) p0.017) and any Paris 0-Is component (OR=10.2; 95% CI 3.18 to 32.4, p0.001).Simple assessment tools allow endoscopists to predict SSA/P-D or HGD/cancer in SSA/Ps ≥20 mm. Correct prediction is limited by failure to recognise SSA/P-D which may mimic conventional adenoma. Understanding the concept of SSA/P-D and the pitfalls of SSA/P assessment may improve detection, recognition and resection and potentially reduce interval cancer.NCT01368289.

Background & Aims Clinically significant postendoscopic mucosal resection bleeding (CSPEB) is the most frequent significant complication of wide-field endoscopic mucosal resection (WF-EMR) of advanced mucosal neoplasia (sessile or laterally spreading colorectal lesions > 20 mm). CSPEB requires resource-intensive management and there is no strategy for preventing it. We investigated whether prophylactic endoscopic coagulation (PEC) reduces the incidence of CSPEB. Methods We performed a prospective randomized controlled trial of 347 patients (mean age, 67.1 y; 55.3% with proximal colonic lesions) undergoing WF-EMR for advanced mucosal neoplasia at 3 Australian tertiary referral centers. Patients were assigned randomly (1:1) to groups receiving PEC (n = 172) or no additional therapy (n = 175, controls). PEC was performed with coagulating forceps, applying low-power coagulation to nonbleeding vessels in the resection defect. CSPEB was defined as bleeding requiring admission to the hospital. The primary end point was the proportion of CSPEB. Results Patients in each group were similar at baseline. CSPEB occurred in 9 patients receiving PEC (5.2%) and 14 controls (8.0%; P = .30). CSPEB was associated significantly with proximal colonic location on multivariate analysis (odds ratio, 3.08; P = .03). Compared with the proximal colon, there was a significantly greater number (3.8 vs 2.1; P = .002) and mean size (0.5–1 vs 0.3–0.5 mm; P = .04) of visible vessels in the distal colon. Conclusions PEC does not significantly decrease the incidence of CSPEB after WF-EMR. There were significantly more and larger vessels in the WF-EMR mucosal defect of distal colonic lesions, yet CSPEB was more frequent with proximal colonic lesions. ClinicalTrials.gov NCT01368731.

Prophylactic Endoscopic Coagulation for the Prevention of Bleeding After Wide Field Endoscopic Mucosal Resection of Large Sessile Colonic Polyps a Prospective Multicenter Randomized Control Trial Farzan Fahrtash-Bahin*, Mahendra Naidoo, Rebecca Sonson, Stephen J. Williams, Luke F. Hourigan, Spiro Raftopoulos, Donald Ormonde, Michael J. Bourke Gastroenterology, Westmead Hospital, Sydney, NSW, Australia; Gastroenterology, Princess Alexandria Hospital, Brisbane, QLD, Australia; Gastroenterology, Sir Charles Gairdner Hospiital, Perth, WA, Australia Background: Clinically significant post colonic endoscopic mucosal resection bleeding (CSPEB) occurs in up to 12% of cases in the right colon and 7% overall. It may be severe and life threatening and requires resource intensive management. Effective therapy to prevent colonic CSPEB has not been described. Observational studies suggest that prophylactic endoscopic coagulation (PEC) significantly reduces bleeding after advanced resection of superficial neoplasms in the upper gastrointestinal tract. Whether PEC of non-bleeding vessels in the colonic wide field endoscopic mucosal resection (WFEMR) defect reduces the rate of CSPEB is unknown. Methods: A prospective multicenter trial (ClinicalTrials.gov NCT01368731) of PEC after WFEMR was performed. Consenting patients undergoing WFEMR for large ( 20mm) sessile or laterally spreading lesions of the colon were enrolled. WFEMR and PEC technique was standardized. After a technically successful and uncomplicated procedure patients were randomized 1:1 to no additional therapy or to receive PEC to non-bleeding vessels within the resection defect using coagulating forceps (soft coagulation, 80 watts). CSPEB was defined as bleeding requiring presentation to hospital. The primary end-point was the rate of CSPEB. This abstract describes the scheduled interim analysis. Results: Over 16 months to November 2012 WFEMR was performed in 427 patients. 55 out of 325 consenting patients were excluded due to pedunculated lesion type or size 20mm (30), incomplete or past resection (16), suspected invasive carcinoma (6) or muscularis propria defect (3). 270 patients (mean age 67 years, 51.6% male) with 276 resected lesions (54.2% right colon) were enrolled. Patients in the PEC (n 138) and non-PEC (n 138) arms were similar at baseline (Table 1). CSPEB occurred in 7 (5.1%) patients in the PEC arm vs 8 (5.8%) patients in the non-PEC arm (p 0.78). CSPEB was not associated with patient age (p 0.32), antiplatelet or anticoagulant use (p 0.89), lesion size (p 0.99) or location (p 0.96). Rates of hospital admission (4.3% PEC vs 5.1% non-PEC, p 0.89) were similar in both arms. No PEC related adverse events or delayed perforation occurred. If the present trend continues 131 patients would require PEC to prevent one CSPEB. Conclusions: This interim analysis suggests that PEC does not decrease the rate of CSPEB. Whilst unlikely to be harmful, PEC does not appear to provide a clinically meaningful benefit to the patient. The trial is continuing to completion.

Aims The NHMRC has published recommendations for screening of patients with a family history of colorectal cancer (CRC). We aimed to assess if referrals and follow-up recommendations in an open access colonoscopy service concur with these guidelines. Methods We prospectively interrogated patients referred for colonoscopy with a family history of CRC concerning the number, relationship and age of such relatives, to assess whether they satisfied NHMRC criteria for screening. Follow-up recommendations were also assessed retrospectively. Results From January 2000 to April 2001 2579 colonoscopies were performed. There were 340 cases with a family history of CRC and 202 of these were asymptomatic. Of these screening cases, mean age was 50 years (range 16–80 years). Referrals were from general practitioners in 92%, gastroenterologists in 5% and other specialists in 2% of cases. NHMRC category Number of patients in category Satisfied all NHMRC criteria for colonoscopic screening at referral Unable to classify 3 0 1 84 0 2 107 87 3 8 8 Total 202 95 There were 87 patients who did not satisfy the criteria for colonoscopic screening (Unable to classify or Category 1). Of these, 25 (29%) were below the recommended age to commence any screening. There were 115 patients (57%) who satisfied the family history criteria for colonoscopic screening (NHMRC Category 2 or 3). Of these, 20 (17%) were below the recommended age to commence screening. Follow-up recommendations were made in 108 patients (53%) and these concurred with NHMRC guidelines in 88 cases (81%). In 16 of the 20 cases where follow-up recommendations did not occur with NHMRC guidelines, the interval to repeat colonoscopy was too short or colonoscopy was recommended rather than annual faecal occult blood testing. Conclusions Less than half the patients being referred for screening colonoscopy for family history of CRC satisfy NHMRC criteria. In the majority of cases this is due to referral of Category 1 patients for screening. Follow-up recommendations, when made, are usually in keeping with NHMRC guidelines.

BACKGROUND: Routine mucosal biopsy in patients undergoing colonoscopy for diarrhoea, in whom macroscopic examination is normal, remains controversial and practice varies widely without clear guidelines. Reported rates of clinically significant microscopic abnormalities vary from 2-27%.It is unclear if ileal biopsy adds anything to colonic biopsy alone. OBJECTIVES: We sought to evaluate the diagnostic yield of colonic and ileal mucosal biopsy in patients undergoing colonoscopy for diarrhoea in whom the macroscopic examination was normal. METHODS: We retrospectively reviewed all colonoscopies performed over a nine year period in a tertiary referral centre with an open access endoscopy service. Cases were selected where the sole indication for colonoscopy was diarrhoea, the musosa was macroscopically normal (other than diverticulosis) and biopsies were performed. Cases were excluded if the examination was inadequate. The histopathology reports of the selected cases were then reviewed. RESULTS: 362 cases were identified. Colonoscopy and biopsy was normal in 260 patients.Ileal biopsies were performed (in addition to colonic biopsies) in 158 cases, none of which revealed clinically significant abnormalities. Clinically significant histological findings were present in 18 cases (5%). Findings included collagenous colitis (5 cases), lymphocytic colitis (1 case), possible lymphocytic colitis (1 case), possible collagenous colitis (1 case), inflammatory bowel disease (2 cases), melanosis coli (2 cases) and significant eosinophil mucosal infiltration (6 cases). 28 patients (8%) had minor histological abnormalities with no specific diagnostic features. The diagnostic yield was highest in patients above 60 years old, where 10% had clinically significant histological abnormalities. All patients with collagenous colitis were female and only 1 was less than 60 years old. CONCLUSIONS: When colonoscopy is normal in patients with diarrhoea, routine colonic biopsy identifies significant pathology in 5% of cases. The diagnostic yield is highest in patients over 60 years old. Routine ileal biopsy is unhelpful.