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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

Objectives This study investigated benefits of routine panendoscopy in staging of oral squamous cell cancer patients. Materials and methods From 2013 to 2017, 194 oral squamous cell cancer patients were staged. Reports of routine flexible panendoscopy including oropharyngolaryngoscopy, bronchoscopy, and esophagogastroduodenoscopy were retrospectively analyzed for diagnoses of inflammation and second primary malignancies (carcinoma in situ or cancer) and compared to results of computed tomography. The effects of alcohol and tobacco history of 142 patients were assessed. Results Overall, a second primary malignancy was detected in seven patients. In four patients this discovery was only found by panendoscopy. One invasive carcinoma (esophagus) was detected as well as three carcinoma in situ. The second primary malignancies were located in the lung (3), esophagus (3), and stomach (1). In one patient index tumor therapy was modified after panendoscopy. Upper gastrointestinal inflammation was present in 73.2% of patients and 61.9% required treatment. About 91.8% of bronchoscopies and 34.5% of panendoscopies were without therapeutic consequences. Patients with higher risk from smoking were more likely to benefit from panendoscopy and to have a Helicobacter pylori infection. Conclusion We do not recommend routine panendoscopy for all oral squamous cell cancer patients. Esophagogastroduodenoscopy benefitted smoking patients primarily concerning the secondary diagnosis of inflammation of the upper digestive tract. Selective bronchoscopy, esophagogastroduodenoscopy, and oropharyngolaryngoscopy should be performed if clinical examination or medical history indicates risks for additional malignancies of the upper aerodigestive tract. Clinical relevance Routine panendoscopy is not recommended in all, especially not in low-risk oral cancer patients like non-smokers and non-drinkers.

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.

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.

Contains fulltext : 205162.pdf (Publisher’s version ) (Open Access) BACKGROUND AND AIMS: Colorectal cancer (CRC) is largely preventable with routine screening and surveillance colonoscopy; however, interval cancers arising from precancerous lesions missed by standard colonoscopy still occur. An increased adenoma detection rate (ADR) has been found to be inversely associated with interval cancers. The G-EYE device includes a reusable balloon integrated at the distal tip of a standard colonoscope, which flattens haustral folds, centralizes the colonoscope's optics, and reduces bowel slippage. The insufflated balloon also aims to enhance visualization of the colon during withdrawal, thereby increasing the ADR. METHODS: In this randomized, controlled, international, multicenter study (11 centers), patients (aged >/=50 years) referred to colonoscopy for screening, surveillance, or changes in bowel habits were randomized to undergo either balloon-assisted colonoscopy by using an insufflated balloon during withdrawal or standard high-definition colonoscopy. The primary endpoint was the ADR. RESULTS: One thousand patients were enrolled between May 2014 and September 2016 to undergo colonoscopy by experienced endoscopists; 803 were finally analyzed (standard colonoscopy n = 396; balloon-assisted colonoscopy n = 407). Baseline parameters were similar in both groups. Balloon-assisted colonoscopy provided a 48.0% ADR compared with 37.5% in the standard colonoscopy group (28% increase; P = .0027). Additionally, balloon-assisted colonoscopy provided for a significant increase in detection of advanced (P = .0033) flat adenomas (P < .0001) and sessile serrated adenomas/polyps (P = .0026). CONCLUSION: Balloon-assisted colonoscopy yielded a higher ADR and increased the detection of advanced, flat, and sessile serrated adenomas/polyps when compared with standard colonoscopy. Improved detection by the G-EYE device could impact the quality of CRC screening by reducing miss rates and consequently reducing interval cancer incidence. (Clinical trial registration number: NCT01917513.).

Sintering is a process of agglomeration of fine particles into porous sinters for blast furnaces. During the sintering process, high volumes of sinter plant gas containing high loads of dust, SO2 and NOX and toxic pollutants, such as heavy metals (e.g., Hg, Pb, Cr and Cd) and PCDD/F, are emitted. The objective of this study was to characterize dusts of different plants as the basis for suggestions of reutilization and treatment options. Dusts, eluates and residues were produced and DOC, T-N, ions and heavy metals were analyzed. The results show that dusts from different plants are very similar in terms of DOC, T-N, Mg, Ca and many heavy metals and only differ in criteria such as suspended solids and ions such as K, Na, Cl and SO4. Based on the high levels of alkalis and low levels of iron, direct recycling into the sinter or furnace process is not recommended. The dissolution of the soluble substances in water reduces the MEROS dust by 90% of the weight and extracts the alkalis. The remaining wastewater needs to be treated to reduce DOC, T-N and some heavy metals. The solid residues can be recycled into the sinter to reduce potential PCDD/F, which are attached to the activated carbon.

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.

Introduction Lower Gastrointestinal bleeding (LGIB) accounts for 20% of GI bleeds, with significant mortality in the elderly and those with comorbidities. There is limited data on the use of Hemospray in LGIB’s. The primary aim was to look at its safety and efficacy in the treatment of LGIB’s. Methods Data was prospectively collected on the use of Hemospray in LGIB’s in 16 Centres in the UK, USA, Germany, France and Spain (January 2016 – November 2019). Hemospray was used as a monotherapy, combination therapy or rescue therapy. Haemostasis was defined as the cessation of bleeding within 5 minutes of Hemospray application. Results 24 patients with LGIB’s were recruited (16 male, 8 female). The cause of bleeding included malignancy (6/24,25%), post procedure (polypectomy/ESD)(5/24,21%), inflammation/angiodysplasia (7/24, 29%). The median lesion diameter was 20 mm (IQR, 25–50). 9/24 (38%) patients were on antiplatelets/anticoagulants. Immediate haemostasis was achieved in 22/24 (92%) patients. 2/19 (11%) had a re-bleed within 7 days, 4/19 (21%) had a re-bleed within 30 days. 2/21 (10%) died within 30 days (all cause mortality). The two patients that failed treatment had surgery. In combination Hemospray was always used as a second or third modality. There was a 78% haemostasis rate in patients on anticoagulants/antiplatelets, 100% immediate haemostasis on patients on no anticoagulants. There were no adverse events associated with Hemospray. Outcomes in the Hemospray treatment subgroups (table 1). Conclusions Hemospray is safe and effective in LGIB’s with 92% haemostasis rates, with better outcomes as a Monotherapy. Anticoagulants have an effect on haemostasis rates (78% vs 100%). Lower GI bleeds are difficult to treat. Hemospray is an effective alternative in situations where access is difficult and there is a large surface of bleeding.

Introduction Upper gastrointestinal bleeding (UGIB) is a leading cause of morbidity. The aim was to look at outcomes in patients with non-variceal UGIBs of all causes treated with Hemospray. Methods Data was collected prospectively (Jan’ 16- Nov’19) from 16 centres in the USA, UK, Germany, France and Spain. Hemospray was used during endoscopy as a monotherapy, dual therapy or rescue therapy. Haemostasis was defined as cessation of bleeding within 5 minutes of Hemospray application. Results 512 patients with non-variceal UGIBs were recruited (343 male, 169 female). The most common cause was peptic ulcers (236/512, 46%). Immediate haemostasis was achieved in 473/512 (92%) patients. Median Blatchford was 11 (IQR, 8–14), median Rockall was 7 (IQR, 6–8). Re-bleeding occurred in 59/404 (15%) patients. There was a 7-day mortality (all cause) of 9% (42/444), 30-day mortality (all cause) was 19% (85/444). The highest haemostasis rates were in the Hemospray monotherapy group (95%). 39 patients did not achieve haemostasis (69% were peptic ulcer related). 14/39 (36%) of these patients had CT embolization, 7/39 (18%) managed conservatively and 3/39 (8%) had surgery. Outcomes in different UGI pathologies (table 1). Conclusion There were high immediate haemostasis rates following treatment of non-variceal UGIBs. The better outcomes were when Hemospray was used in UGIB’s post endotherapy, malignancy and Angiodysplasia. In malignancies it can bridge towards surgery/chemoradiotherapy, and post endotherapy it can provide definitive haemostasis with low re-bleed rates.

Introduction Early treatment for variceal bleeding is recommended within 12 hours to improve outcomes. Endoscopic therapy in acute variceal bleeding can be technically difficult and not always successful and a bridge is sometimes required towards definitive therapy. Aim of this study was to look at outcomes in patients with upper gastrointestinal bleeds (UGIB’s) secondary to varices. Methods Data was collected prospectively (Jan’16- Nov’19) from 16 centres in the USA, UK, Germany, France and Spain. Hemospray was used during emergency endoscopy for a variceal UGIB as a monotherapy, dual therapy or rescue therapy once standard methods have failed. Haemostasis was defined as cessation of bleeding within 5 minutes. Results 12 patients had Hemospray treatment following a variceal UGIB (10 male, 2 female). 10 oesophageal varices, 2 gastric varices. The median Rockall was 8 (IQR, 7–8). The median Blatchford was 15 (IQR, 13–17). The immediate haemostasis rate was 75%. There were no re-bleeds. 4 patients were treated with Hemospray monotherapy, 3 with combination therapy and 5 with rescue therapy. Hemospray was always given after oesophageal banding/injection sclerotherapy in the combination/rescue therapy cohorts. 4/9 patients died within 7 days, 3 out of these 4 patients did not achieve initial haemostasis with Hemospray. Outcomes in the Hemospray subgroups (table 1). Conclusions The immediate haemostasis rate was 75% in variceal UGIBs following treatment with Hemospray. In this cohort there is no re-bleeding. This suggests that Hemospray may play a role as bridging therapy in variceal bleeds which are difficult to control, towards repeat definitive therapy.

Background Upper gastrointestinal bleeding (UGIB) is a leading cause of morbidity and is associated with a 2 % – 17 % mortality rate in the UK and USA. Bleeding peptic ulcers account for 50 % of UGIB cases. Endoscopic intervention in a timely manner can improve outcomes. Hemostatic spray is an endoscopic hemostatic powder for GI bleeding. This multicenter registry was created to collect data prospectively on the immediate endoscopic hemostasis of GI bleeding in patients with peptic ulcer disease when hemostatic spray is applied as endoscopic monotherapy, dual therapy, or rescue therapy. Methods Data were collected prospectively (January 2016 – March 2019) from 14 centers in the UK, France, Germany, and the USA. The application of hemostatic spray was decided upon at the endoscopist’s discretion. Results 202 patients with UGIB secondary to peptic ulcers were recruited. Immediate hemostasis was achieved in 178/202 patients (88 %), 26/154 (17 %) experienced rebleeding, 21/175 (12 %) died within 7 days, and 38/175 (22 %) died within 30 days (all-cause mortality). Combination therapy of hemostatic spray with other endoscopic modalities had an associated lower 30-day mortality (16 %, P Conclusions This is the largest case series of outcomes of peptic ulcer bleeding treated with hemostatic spray, with high immediate hemostasis rates for bleeding peptic ulcers.

Complete esophageal obstruction (CEO) is a rare complication after radiochemotherapy that dramatically impairs quality of life. Within this study, we assessed the outcome of two different endoscopic techniques for lumen restoration in patients with CEO. 17 patients were included. Esophageal recanalization was performed in an antegrade approach (Group A) or through combined antegrade and retrograde recanalization and dilatation (CARD, Group B). Technical success, complications, and dysphagia development during follow-up (FU) were compared between the groups. In Group A (n = 6), esophageal recanalization was performed by a single endoscopist with a median duration of 47 min. In two patients, antegrade recanalization led to formation of a false lumen (i.e., submucosal tunneling) followed by mediastinitis. In Group B, 21 CARD procedures were performed in 11 patients with a technical success rate of 100%. Procedure time was longer compared to Group A; however, no intra- or postprocedural complications were observed in Group B. In our experience and cohort, CARD was a successful procedure for recanalization of CEO, which exhibits a more favorable safety profile over antegrade recanalization. Further randomized studies to evaluate the treatment of CEO with CARD are needed.

Introduction: Endoscopy is a key technique for the surveillance of patients with inflammatory bowel diseases (Crohn's disease (CD) and ulcerative colitis). Indication to perform endoscopy for surveillance includes assessment of response to therapy, postoperative surveillance, and surveillance for intraepithelial neoplasia. Methods: In addition to personal experience, a literature search was performed and the guidelines were consulted. Results and Conclusion: Endoscopy is the gold standard in the long-term assessment of mucosal healing and in the short-term control of response to intensified therapy. For postoperative surveillance in CD, mucosal changes (as graded by the Rutgeerts score) are predictive of clinical recurrence. For neoplasia surveillance, virtual chromoendoscopy has not (yet) replaced conventional chromoendoscopy. Surveillance can be optimized by the use of high-definition endoscopes as well as (pan-)chromoendoscopy and requires time to scrutinize the mucosa. This approach seems to be superior to random biopsies.

Diagnostic imaging of jejuno-ileal neuroendocrine tumors (NETs) has been described as challenging. Follow-up requires the detection of metastatic spread as well as screening for local recurrence. Multimodal imaging concepts must often be applied.We report the case of a 45-year-old man with a history of ileal NET. At 2 points in follow-up of our patient, information provided by high-end ultrasound changed prognosis and treatment considerably: when positron emission tomography/computed tomography newly detected suspected hepatic metastases, contrast-enhanced ultrasound correctly identified the lesions as intrahepatic vascular shunts. Moreover, profound B-mode ultrasound solely detected ileal recurrence, leading to early removal of the tumor.Diagnostische Bildgebung bei jejuno-ilealen neuroendokrinen Tumoren (NETs) stellt gemeinhin eine Herausforderung dar. In der Nachsorge ist sowohl auf die Detektion möglicher Metastasen als auch auf das Auftreten von Lokalrezidiven zu achten. Oft sind hierfür multimodale bildgebende Ansätze notwendig.Wir berichten über den Fall eines 45-jährigen Patienten mit einem ilealen NET in der Vorgeschichte. An zwei Punkten in der Nachsorge des Patienten lieferte high-end Ultraschall Informationen, die sowohl die Prognose als auch das Behandlungskonzept des Patienten maßgeblich beeinflussten. Im PET/CT neu aufgetretene und als hoch metastasensuspekt beschriebene Läsionen wurden im CEUS korrekt als intrahepatische vaskuläre Shunts erkannt. Des Weiteren detektierte fundierter B-Bild-Ultraschall als einziger ein ileales Rezidiv des NET, was eine frühe Resektion des Tumors ermöglichte.

Management of intestinal strictures associated with Crohn's disease (CD) is clinically challenging despite advanced medical therapy directed toward mucosal healing to positively influence the natural course of CD-associated complications. Although medical therapy is available for inflammatory strictures, therapy of fibrostenotic strictures is the domain of surgery and endoscopy. Endoscopic balloon dilation (EBD) has been recognized as a well-established first-line procedure in terms of safety and efficacy. Although surgery is a valuable treatment modality for the management of CD-related strictures, EBD can help prevent multiple surgical interventions, which might in the long-term lead to a risk of short bowel syndrome. In this review we discuss requirements, techniques, safety, short- and long-term outcomes, as well as combinations of this procedure with surgical and medical treatment in CD-associated intestinal strictures.

ObjectiveEndoscopic full-thickness resection (EFTR) is a novel treatment of colorectal lesions not amenable to conventional endoscopic resection. The aim of this prospective multicentre study was to assess the efficacy and safety of the full-thickness resection device.Design181 patients were recruited in 9 centres with the indication of difficult adenomas (non-lifting and/or at difficult locations), early cancers and subepithelial tumours (SET). Primary endpoint was complete en bloc and R0 resection.ResultsEFTR was technically successful in 89.5%, R0 resection rate was 76.9%. In 127 patients with difficult adenomas and benign histology, R0 resection rate was 77.7%. In 14 cases, lesions harboured unsuspected cancer, another 15 lesions were primarily known as cancers. Of these 29 cases, R0 resection was achieved in 72.4%; 8 further cases had deep submucosal infiltration >1000 µm. Therefore, curative resection could only be achieved in 13/29 (44.8%). In the subgroup with SET (n=23), R0 resection rate was 87.0%. In general, R0 resection rate was higher with lesions ≤2 cm vs >2 cm (81.2% vs 58.1%, p=0.0038). Adverse event rate was 9.9% with a 2.2% rate of emergency surgery. Three-month follow-up was available from 154 cases and recurrent/residual tumour was evident in 15.3%.ConclusionEFTR has a reasonable technical efficacy especially in lesions ≤2 cm with acceptable complication rates. Curative resection rate for early cancers was too low to recommend its primary use in this indication. Further comparative studies have to show the clinical value and long-term outcome of EFTR in benign colorectal lesions.Trial registration numberNCT02362126; Results.

Background Mucosal healing is an important goal in the treatment of ulcerative colitis (UC). The newly published PICaSSO score characterises subtle mucosal and vascular changes and defines mucosal healing. 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 and 3 (Pentax, Japan) and inflammatory activity was assessed using UCEIS and PICaSSO. Biopsies were taken for the histological assessment using Robarts Histological Index (RHI) and Nancy. Follow-up was obtained at 12 months. Results A total of 278 patients were recruited (Table 1). The diagnostic performance in predicting histologic healing is shown in Table 2. When using PICaSSO score of ≤3 for mucosal and vascular architecture the AUROC to predict healing by RHI is 0.79 (95% CI 0.74–0.85) and 0.73 (95% CI 0.68–0.80) respectively and when using the Nancy score the AUROC is 0.78 (95% CI 0.72–0.84) and 0.77 (0.71–0.84). A total PICaSSO score of ≤8 and UCEIS score of ≤1 predicts remission at 12 months with an AUROC of 0.73 (0.65–0.80) and 0.71 (0.64–0.79). A Kaplan–Meier curve shows a favourable survival probability without relapse with a PICASSO score of ≤8 (Figure 1). Conclusion This real-life validation study shows the PICaSSO score can predict accurately histological healing and long-term remission and can be a useful tool in the management of UC.

Background and aims Endoscopic retrograde cholangiopancreatography (ERCP) is rarely performed in newborns, and the risk of post-ERCP pancreatitis (PEP) has not been defined in this age group. We therefore performed a European multicentre analysis of PEP rates and risk factors in children aged ≤1 year. Patients and methods Based on a sample size estimation, 135 consecutive ERCPs in 126 children aged ≤1 year were evaluated from five European centres, and the first ERCP per child analysed. All ERCPs and clinical reports were reviewed manually for PEP and associated risk factors. All ERCPs were performed by endoscopists with high ERCP expertise. Results No PEP was observed (0/126, 0.0%, CI 0–2.9%) despite the formal presence of multiple risk factors and despite lack of PEP prophylaxis (except one patient having received a pancreatic duct stent). The PEP rate was significantly lower than the PEP rate expected in adults with similar risk factors. Conclusions ERCP in children aged ≤1 year is safe in terms of PEP. The PEP risk is significantly lower in children aged ≤1 year than in adults, therefore no PEP prophylaxis seems to be needed in young children. Risk factors from adults may not apply to children under 1 year. Reluctance to perform diagnostic ERCP in suspected biliary anomalies should not be based on presumed PEP risk.

Introduction Patients with tumour related upper gastrointestinal bleeds (UGIBs) are challenging to treat. Hemospray (Cook Medical, North Carolina, USA) is a novel haemostatic powder for GI bleeding. The primary aim was to look at outcomes of UGIBs secondary to tumours who had Hemospray therapy in 13 centres. Methods Data was prospectively collected on the use of hemospray from specialist centres in the UK, France, Germany (Jan’16-September’18). Hemospray was used for UGIBs secondary to tumours as a monotherapy, dual-therapy with standard haemostatic techniques or rescue therapy. Haemostasis was defined as the cessation of bleeding within 5 minutes of the application of hemospray. Results 75 patients with tumoural UGIBs were recruited (51 males, 24 females, 22/75 (29%) oesophageal, 49/75 (65%) gastric, 4/75 (5%) doudenal). The median rockall score was 8 (IQR,7–9). Immediate haemostasis was achieved in 73/75 (97%) of patients, 7/65 (11%) had a rebleed, 12/65 (18%) died within 30 days (all-cause mortality). Based on the baseline average total rockall score, the expected rebleed rate is 25–40%, and expected mortality rate was 40–45% in our cohort. 100% immediate haemostasis was achieved in duodenal and gastric tumours, and 91% in oesophageal tumours. Outcomes with mono/combination therapy and rescue therapy (table 1) Conclusions Hemospray is effective for achieving immediate haemostasis in UGIBs secondary to upper GI tumours, which are considered difficult to treat. When considering average rockall score the rebleed and mortality rate is better than predicted rates. Haemostasis is achieved in the majority allowing for patient stabilization and providing time for surgery/radiotherapy.

Introduction Peptic ulcers are the commonest cause of upper Gastrointestinal bleeding (UGIB). Hemospray (Cook Medical, North Carolina, USA) is a novel haemostatic powder aimed to treat UGIB. The aim of this study is to look at outcomes in patients with peptic ulcer GI bleeds treated with hemospray in 13 centres. Methods Data was prospectively collected on hemospray use in UGIBs in the UK, France and Germany (Jan’16-Sept’18). Hemospray was used for peptic ulcer UGIBs as a monotherapy, dual-therapy with standard haemostatic techniques or rescue therapy. Haemostasis was defined as cessation of bleeding within 5 minutes of hemospray application. Results 196 patients with UGIBs secondary to peptic ulcers were recruited (133 M, 63 F, 123/196(63%) duodenal, 44/196(22%) gastric, 29/196(15%) oesophageal). Immediate haemostasis was achieved in 171/196(87%) patients. The median rockall score was 7 (IQR, 6–8). Rebleeding rates were significantly lower in forrest 2a relative to current predicted rebleeding rates based on forrest classifications, 2/21(10%, P Outcomes with different Forrest classifications (table 1) Conclusions Hemospray is effective in achieving immediate haemostasis in peptic ulcer UGIBs. The baseline Blatchford/rockall scores in our cohort are high with patients recruited from tertiary centres with high-risk cases. The rebleeding and mortality rates are in keeping/below the predicted rate based on the scores. The best outcome with hemospray was with forrest 2a ulcers.

Background/aims Ustekinumab is effective in active Crohn's disease. In a retrospective study we assessed the clinical outcome in nonresponders to anti-tumor necrosis factor therapy, and/or conventional therapy and/or the α4β7-integrin inhibitor vedolizumab. As approval study populations do not always reflect the average "real world" patient cohort, we assessed weather patients who would not have qualified for approval studies show similar outcomes. Methods Forty-one patients with mild to severe active Crohn's disease were treated with ustekinumab (intravenous 6 mg per kg/body weight) followed by subcutaneous ustekinumab (90 mg) at week 8. Depending on the clinical response maintenance therapy was chosen every 8 or 12 weeks. Clinical response was defined by Crohn's Disease Activity Index (CDAI) decline, decline of stool frequency or clinical improvement. Inclusion criteria for approval studies were assessed. Results The 58.5% (24/41) showed clinical response to ustekinumab. The 58.3% of this group (14/24) achieved clinical remission. Clinical response correlated significantly with drop of stool frequency and improvement of CDAI score. The 39 out of 41 patients had no side effects and we observed no serious infections. About a third of our patients would not have met ustekinumab approval study criteria. However, patients who did not meet study criteria showed clinical improvement numerically in the same range compared to patients who would have qualified for approval studies. Conclusions Ustekinumab is effective, safe and well tolerated in a highly therapy refractory patient cohort. Even though a reasonable number of patients did not meet ustekinumab approval study criteria, approval study results seem to be representative to the overall patient cohort.

Background & Aims: Little is known about the effects of endoscopic balloon dilation (EBD) for strictures of the upper gastrointestinal (UGI) tract in patients with Crohn's disease (CD). We performed a pooled analysis of the efficacy and safety of EBD for UGI CD-associated strictures. Methods: We searched Embase, Medline, and the Cochrane library, as well as bibliographies of relevant articles, for cohort studies of adults with CD and strictures of the stomach or duodenum (up to the ligament of Treitz) who underwent EBD through December 2016. We obtained data from 7 international referral centers on 94 patients who underwent 141 EBDs. We performed a patient-level meta-analysis of data from published and unpublished cohort studies to determine mechanical and clinical success. We performed a time-to-event analysis to assess symptom recurrence and need for redilation or surgery. The patients analyzed had strictures of the duodenum (n = 107), stomach (n = 30), or spanning both (n = 4). Results: The rate of technical success for EBD was 100%, with 87% short-term clinical efficacy; major complications arose from 2.9% of all procedures. During a median follow-up period of 23.1 months, 70.5% of patients had a recurrence of symptoms, 59.6% required redilation, and 30.8% required surgical intervention. Patients whose disease was located in the small bowel had a higher risk for symptom recurrence (hazard ratio [HR], 2.1; P = .003). Asian race (HR, 2.8; P < .001) and location of disease in the small bowel (HR, 1.9; P = .004) increased the need for redilation. Prestenotic dilation was a risk factor for needing surgery earlier (HR, 1.9; P = .001). Conclusions: In a meta-analysis, we found EBD for CD-associated strictures of the UGI to be an effective alternative to surgery, with a high rate of short-term technical and clinical success, moderate long-term efficacy, and an acceptable rate of complications.

ObjectiveEndoscopic full-thickness resection (EFTR) has shown efficacy and safety in the colorectum. The aim of this analysis was to investigate whether EFTR is cost-effective in comparison with surgical and endoscopic treatment alternatives.DesignReal data from the study cohort of the prospective, single-arm WALL RESECT study were used. A simulated comparison arm was created based on a survey that included suggested treatment alternatives to EFTR of the respective lesions. Treatment costs and reimbursement were calculated in euro according to the coding rules of 2017 and 2019 (EFTR). R0 resection rate was used as a measure of effectiveness. To assess cost-effectiveness, the average cost-effectiveness ratio (ACER) and the incremental cost-effectiveness ratio (ICER) were determined. Calculations were made both from the perspective of the care provider as well as of the payer.ResultsThe cost per case was €2852.20 for the EFTR group, €1712 for the standard endoscopic resection (SER) group, €8895 for the surgical resection group and €5828 for the pooled alternative treatment to EFTR. From the perspective of the care provider, the ACER (mean cost per R0 resection) was €3708.98 for EFTR, €3115.10 for SER, €8924.05 for surgical treatment and €7169.30 for all pooled and weighted alternatives to EFTR. The ICER (additional cost per R0 resection compared with EFTR) was €5196.47 for SER, €26 533.13 for surgical resection and €67 768.62 for the pooled rate of alternatives. Results from the perspective of the payer were similar.ConclusionEFTR is cost-effective in comparison with surgical and endoscopic treatment alternatives in the colorectum.

Background: To evaluate the benefits of teduglutide in a real-life setting, we analyzed the data of 14 patients with short bowel syndrome treated with teduglutide. Additionally, we studied glucagon-like peptide 2 (GLP-2) receptor expression in samples of small intestinal and colonic tissue to provide explanations for clinical observations. Methods: Stool frequency and consistency, sensation of thirst, parental calorie or fluid uptake and the number of days on parenteral support per week were collected for up to 2 years. Quantitative real-time polymerase chain reaction of the GLP-2 receptor in healthy controls was performed to better understand clinical response in different patient subgroups. Results: There was a significant reduction in parenteral support after 24 and 48 weeks (by 11.0 and 36.6%, respectively; p < 0.05). Further major improvements were made in several patients after over 1 year (reduction by 79.3%, p < 0.05). The proportion of patients who reduced parenteral support by at least 20% was 33.3%, 54.5% and 71.3% after 24 weeks, 48 weeks and beyond 1 year, respectively. Patients on daily parenteral support showed late but strong amelioration. The reduction of thirst was the earliest marker for response. While stool consistency increased ( p < 0.01), stool frequency decreased ( p < 0.05) significantly after 12 weeks. This reduction was even more pronounced in patients with colon in continuity. Supporting these clinical observations, we found a stronger physiological expression of the GLP-2 receptor in the colon than in the small intestine. Conclusions: Patients benefit from teduglutide in a real-life setting, but in contrast to randomized, controlled studies reduction of parenteral support took longer. We identified early clinical markers of response, such as stool consistency and frequency as well as sensation of thirst. Clinical and molecular observations support the role of the colon as an important target organ of teduglutide.

Introduction Acute gastrointestinal bleeding (AGIB) carries poor outcomes unless prompt endoscopic haemostasis is achieved. Hemospray is a novel intervention that creates a mechanical barrier over bleeding sites when applied endoscopically. Primary aim of this international prospective multicentre registry is to collect outcomes of patients with AGIB after endoscopic Hemospary application. Secondary outcomes of rebleeding, disease and procedure specific outcomes are also collected. Method Prospective data (Jan2016-Jan2018) from 11 centres across UK, France and Germany collected. Hemospray used as mono therapy, dual-therapy with standard haemostatic techniques or rescue therapy once standard methods failed. Immediate haemostasis defined as cessation of bleeding within 5 min after application of Hemospray. Rebleeding defined as subsequent drop in Hb (>2 g/L), haematemesis, persistent melaena with haemodynamic compromise post therapy. Results 275 cases recruited worldwide(203 M and 72 F). Median pretreatment Blatchford score (BS) 11 for all cases. 246 patients (89%) achieved immediate haemostasis after endoscopic therapy with Hemospray (table 1). Similar haemostasis rates noted in the Hemospray monotherapy (92%), combination therapy (90%) and rescue therapy (85%) group. Peptic ulcer bleed was the most common pathology (53%) and forrest Ib the most common lesion type (66%). 29 patients did not achieve immediate haemostasis.Median BS was higher in this group at 13 (IQR 11–16, p Conclusion These data show high rates of immediate haemostasis (89%). Forrest Type 1b lesions have a higher rate of unsuccessful haemostais and increased risk of rebleeding after therapy. Patients with rebleeding and unsuccessful treatment had higher BS at baseline. The expansion of this international registry will provide data on the efficacy of Hemospray in various disease and patient types over the coming years.

Nonoperative management (NOM) of rectal cancer after radiochemotherapy (RtChx) in patients with a clinical complete response is an emerging strategy with the goal to improve quality of life without compromising cure rates. However close monitoring with both magnetic resonance imaging (MRI) and rectoscopy is required for the early detection of possible local regrowths. We therefore performed a cost analysis comparing the costs of immediate surgery with the costs for MRI and rectoscopy during surveillance as in the upcoming CAO/ARO/AIO-16 trial.MRIs and rectoscopies of patients with a clinical complete response after RtChx over the course of 5 years were simulated and compared with immediate surgery after RtChx. Transition probabilities between health stages (no evidence of disease, local regrowth and salvage surgery, distant failure) were derived from the literature. Costs for ambulatory imaging and endoscopic studies were calculated according to the "Gebührenordnung für Ärzte" (GOÄ), costs for surgery based on the diagnosis-related groups system. Three different scenarios with higher costs for salvage surgery or higher regrowth rates were simulated.A patient without disease recurrence will generate costs for MRI and rectoscopy of 6344 € over 5 years compared with costs of 14,511 € for immediate radical surgery. When 25% local regrowths with subsequent salvage surgery were included in the model, the average costs per patient are 8299 €. In our simulations a NOM strategy was cost-saving compared with immediate surgery in all three scenarios.A NOM strategy with an intensive surveillance using MRI and rectoscopy will produce costs that are expected to remain below those of immediate surgery.

Recurrent Pyogenic Cholangitis (RPC) or Primary Hepatolithiasis is a common disease of the biliary tract in Asia, whereas it is usually not seen in Europeans. With increasing global mobility, the disease will be encountered in Europe more frequently, too. It should therefore be considered as a differential diagnosis in patients from endemic countries with recurrent symptoms of cholestasis/cholangitis and bile duct dilations, strictures and hepatolithiasis. In this case report, we present the history of a 37-year old patient from Sri Lanka and describe typical aspects of RPC. The patient presented at our hospital with scleral jaundice and pruritus. In the past she had been treated for septic cholangitis. Diagnosis in our patient was made after laboratory tests, MRT/MRCP and ERC. She was treated interventionally by ERC and is now monitored on a regular basis.

Background: Development of perianal fistulas are a common feature of Crohn's disease (CD). Consequences are severe impairment of quality of life as well as potentially life-threatening complications like abscess formation or bacterial sepsis. Therefore, appropriate treatment is an important task in the management of CD. Methods: This review describes the epidemiology, pathogenesis, diagnosis, and conservative medical treatment of perianal CD with regard to the available literature. In February 2015, a PubMed search was performed with the following terms (combined and separate): ‘Crohn's disease management', ‘Crohn's disease complications', ‘perianal Crohn's disease', ‘fistulizing Crohn's disease', ‘perianal fistulas', ‘fistula healing', ‘fistula closure'. From the search results, 36 articles were chosen as core elements of this review. Results: Pelvic magnetic resonance imaging and rectal endosonography are established diagnostic approaches to evaluate perianal fistulas in conjunction with endoscopy. Antibiotics, thiopurines, and calcineurin inhibitors are useful agents in the management of perianal CD. The availability of anti-TNF-alpha therapies has substantially changed the prospects and goals of medical treatment, and fistula healing seems to be possible in a substantial proportion of patients. Conclusion: Antibiotics and several immunosuppressive drugs have improved the treatment of fistulizing CD and should be combined with surgical measures.

Complete esophageal obstruction after (chemo)radiation for head and neck cancers is rare. However, inability to swallow one’s own saliva strongly inflicts upon quality of life. Techniques for endoscopic recanalization in complete obstruction are not well established. We assessed the efficacy and safety of rendezvous recanalization. We performed a retrospective review of all patients who underwent endoscopic recanalization of complete proximal esophageal obstruction after radiotherapy between January 2009 and June 2016. Technical success was defined as an ability to pass an endoscope across the recanalized lumen, clinical success by changes in the dysphagia score. Adverse events were recorded prospectively. 19 patients with complete obstruction (dysphagia IV°), all of whom had failed at least one trial of conventional dilatation, underwent recanalization by endoscopic rendezvous, a combined approach through a gastrostomy and perorally under fluoroscopic control. Conscious sedation was used in all patients. In 18/19 patients (94.7%), recanalization was technically successful. In 14/18 patients (77.8%), the post-intervention dysphagia score changed to ≤ II. Three patients had their PEG removed. Factors negatively associated with success were obstruction length of 50 mm; and tumor recurrence for long-term success. No severe complications were recorded. Rendezvous recanalization for complete esophageal obstruction is a reliable and safe method to re-establish luminal patency. Differences between technical and clinical success rates highlight the importance of additional functional factors associated with dysphagia. Given the lack of therapeutic alternatives, rendezvous recanalization is a valid option to improve dysphagia.

The relative contribution of psychological factors to the onset and course of inflammatory bowel diseases (IBD) is a matter of constant debate since its beginning, as is the clinical need and the efficacy of psychotherapeutic interventions. However, the perspective of patients with IBD has largely been ignored in this debate.Psychometric tests including the Short-Form IBD Questionnaire (SIBDQ), the ADAP test measuring demand for psychotherapy, and the Fear-of-Progression Questionnaire Short Form as well as disease-related questions were positioned on the internet between December 2014 and January 2016. The study was advertised through DCCV (German branch of the European Federation of Crohn's and Ulcerative Colitis Associations).n = 631 patients responded, and complete data from n = 578 (356 Crohn's disease, 219 ulcerative colitis, 3 unclear) were available for analysis. n = 296 had previous experiences with psychotherapy, whereas n = 282 had not. This distribution clearly determined the factor "demand for psychotherapy" (chi-square = 23.7, P0.001). When all available data were entered into a (stepwise-forward) regression model, psychotherapy demand was dependent on previous experience (P0.001), fear of progression (P0.001), quality of life (P = 0.001), smoking (P = 0.003), and previous surgery (P = 0.005) with the total model explaining 29.7% of the variance. The total explained variance of this model was higher in ulcerative colitis (37.6%) than in Crohn's disease alone (25.4%).The demand for psychotherapy as additional therapy in IBD depends on previous experience with psychotherapy, fear for disease progression but also other disease or social characteristics and quality of life.

Low-grade appendiceal mucinous neoplasms (LAMNs) are neoplastic lesions with potential progression to pseudomyxoma peritonei (PMP). In most cases, diagnosis is made because of suspected acute appendicitis or incidentally by computed tomography (CT). However, incidental diagnosis during colonoscopy is rare. We present the case of a 63-year-old man with a LAMN type 1 lesion, diagnosed at routine colonoscopy for surveillance of ulcerative colitis. Because in earlier surveillance colonoscopies, this lesion was misinterpreted as fecal polution, for the first time, this case describes retrospectively a 3-year endoscopic follow-up of LAMN type 1, underlining the benign course of these kind of lesions compared to type 2 lesions with submucosal infiltration. Even though endoscopy and sonography are not accepted as method of choice to detect LAMN lesions, our case highlights their role regarding diagnosis of small lesions, as CT scan was not able to detect the lesion in our case. Even though LAMNs are rare, awareness of LAMN lesions in routine colonoscopy is favorable as potential progression to PMP can not be ruled out.

High definition endoscopy is the accepted standard in colonoscopy. However, an important problem is missed polyps.Our objective was to assess the additional adenoma detection rate between high definition colonoscopy with tone enhancement (digital chromoendoscopy) vs. white light high definition colonoscopy.In this prospective randomized trial patients were included to undergo a tandem colonoscopy. The first exam was a white light colonoscopy with removal of all visualized polyps. The second examination was randomly assigned in a 1:1 ratio as either again white light colonoscopy (Group A) or colonoscopy with tone enhancement (Group B). Primary endpoint was the adenoma detection rate during the second withdrawal (sample size calculation - 40 per group).67 lesions (Group A: n=34 vs. Group B: n=33) in 80 patients (mean age 61 years, male 64%) were identified on the first colonoscopy. The second colonoscopy detected 78 additional lesions: n=60 with tone enhancement vs. n=18 with white light endoscopy (p0.001). Tone enhancement found more additional adenomas (A n=20 vs. B n=6, p=0.006) and identified significantly more missed adenomas per subject (0.5 vs. 0.15, p=0.006).High definition plus colonoscopy with tone enhancement detected more adenomas missed by white light colonoscopy.