Acute upper gastrointestinal bleeding (UGIB) is a common medical emergency that has a 10% mortality rate,1 requiring specialist input and management.2 We conducted a retrospective review last year which showed that the mean length of stay (days) was shorter in the GI group: 5.5 ± 5.7 vs 15.7 ± 20.8 (p = 0.02).3 We conducted a prospective analysis to assess if the above results held true.
Methods
A prospective review of case-notes (Electronic patient record-EPR) was conducted for all patients admitted to Kings College hospital with suspected UGIB between January and September 2013. Patients were divided as to whether they came immediately under the care of Gastroenterologists (GI) or general physicians (non-GI) after initial evaluation in the Acute Admission Unit. Patients were assigned on the basis of bed availability in a ward-based system. Statistical comparisons were made as appropriate with two tailed t-test or chi- squared test.
Results
138 patient episodes were reviewed of which 63 and 75 were treated by GI and Non-GI physicians. The two groups were broadly similar in their baseline characteristics. Mean length of stay (days) was significantly shorter in the GI group: 6.6 ± 5.6Vs 10.66 ± 11.3 (p = 0.006). Other comparators are shown in the table.
Conclusion
The length of stay of patients with UGIB is significantly shorter when receiving specialist care. In line with previous reports,4 we found that the incidence of UGIB was higher in males. Patients managed by GI physicians received less blood transfusion compared to the Non-GI physicians. The time to endoscopy was significantly shorter when receiving specialist care. Mortality rates in both groups compared favourably to the national average.
References
CG141 Scope for improvement: A toolkit for a safer Upper Gastrointestinal Bleeding (UGIB) service. www.bsg.org.uk Venkatachalapathy SV, Grasso N, Hayee B et al., Specialist care of in-patients with non-variceal upper gastrointestinal bleeding is associated with a dramatically shorter length of stay. Gut 2013;62:A10 doi:10.1136 Lanas A, García-Rodríguez LA, Polo-Tomás M et al., Am J Gastroenterol 2009;104:1633-41
The incidence of benign oesophageal strictures is 0.5% in patients with dyspeptic symptoms.1 It affects the quality of life by causing dysphagia, regurgitation and in severe cases weight loss. The first line of management is balloon or bougie dilatation. There is ambiguity about the complication rates associated with this procedure. We therefore did a systematic review and metanalysis on complications (bleeding and perforation) associated with endoscopic dilatation.
Methods
We searched several electronic databases including Pubmed for full journal articles published after 1990 reporting on the use of endoscopic dilatation using bougies or balloons in the treatment of beingn oesophageal strictures. We hand searched the reference lists of all retrieved articles. Cohort or prospective studies involving 10 or more adult patients were included in the analysis. Studies on corrosive/caustic strictures and radiological non-endoscopy guided diltations were excluded. We calculated the pooled proportion of patients who had a complication (perforation or bleed) to therapy in the selected studies. Heterogeneity between the studies was assessed using the I2 statistic.
Results
Our search identified 32 studies that were included in the final analysis (26 cohort studies and 6 randomised control trials). There were 11 studies that reported on balloon, 8 on bougie and 13 studies reported on both balloon and bougie dilatations. There were 18104 patients, 7195 balloon dilations and 15,936 bougie dilations. There were 7711 (42.5%) males and 7305 (40.3%) females. The pooled rate of perforation was 0.5% (95% CI, 0.3–0.8, I2–7.5%) and 0.3% (95% CI, 0.2–0.5, I2–41.1%) for balloon and bougie respectively. The rate of bleeding was 0.6% (95% CI 0.4–1.1, I2–17.1%), and 0.3% (95% CI, 0.2–0.8, I2–60.6%) for balloon and bougie dilatations respectively.
Conclusion
This large meta analysis on 18104 patients shows that the risk of perforation and bleeding is low and comparable in both endoscopic guided balloon and bougie dilatations. The rates are lower than the commonly accepted figure of 1% and should be reassuring to both patients and endoscopists.
Reference
1 Breslin NP, Thomson ABR, Bailey RJ, et al. Gastric cancer and other en- doscopic diagnoses in patients with benign dyspepsia. Gut 2000;46.
Pancreatic fluid collections (PFC) are a common local complication of pancreatitis with incidences of 5–16% and 20–40% in acute and chronic pancreatitis, respectively.1 Classification of PFC includes acute peripancreatic fluid collection, pancreatic pseudocyst, acute necrotic collection and walled-off necrosis (WON). A new lumen-apposing, covered self-expanding metal stent on a catheter-based delivery system (Hot AXIOS, Boston Scientific) may have higher technical success rates, easier deployment and lower migration than plastic stents. We present the first multicentre prospective case series from the UK and Ireland to assess success and complication rates associated with Hot AXIOS stent for the drainage of PFC.
Methods
All adult patients who had Hot AXIOS stent placement for PFC from July 2015-February 2016 were included. Eight centres participated (London, Glasgow, Edinburgh, Newcastle, Cambridge, Manchester, Dublin and Leeds). All patients had CT of the PFC prior to placement. Data including technical success, resolution of collection, complications and stent migration were collected.
Results
Forty patients were treated with a single Hot AXIOS stent in each case. The median age was 57 years (range 31–78). 25 were male and 15 female. Indications were WON (24), pseudocyst (15) and abscess.1 The median size of the PFC was 11 cm (4–20 cm). Thirty-eight patients (95%) had trans-gastric stents, 1 had trans-duodenal and 1 had a trans-oesophageal stent. Procedures were technically successful in all patients. Of 22 patients with available follow-up data to date, the collection resolved in 19 (86%) and reduced in size in 3 (14%). The median time to resolution was 36 (7–208) days. Twelve patients (30%) had 33 necrosectomies and/or endoscopic lavage following stent insertion. Stents migrated out in 2 patients and was displaced during necrosectomy in 1. Serious adverse events occurred in 1/40 (2.5%): a small bowel obstruction resulting from stent migration, managed surgically. There was no procedure related or 30 day mortality (data available in 27 patients).
Conclusion
This multicentre case series demonstrates that the Hot AXIOS system is safe and effective in draining PFC with a technical success rate of 100% and low serious adverse event rate.
Reference
1 Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis—2012: Revision of the Atlanta classification and definitions by international consensus. Gut 2013.
Introduction Acute upper gastrointestinal bleeding (AUGIB) is a potentially life threatening condition, resulting in 7.4% all-cause mortality in patients receiving endoscopy in the UK National audit in 2007 [1]. Formal, out-of-hours (OOH) endoscopy rotas for AUGIB are typically delivered by consultant gastroenterologists and have been shown to reduce waiting time to endoscopy and improve mortality. Leeds Teaching Hospitals NHS Trust (LTHT) has a Speciality registrar (SpR) led OOH on-call rota staffed by junior SpRs supervised by more senior trainees. We prospectively audited the LTHT SpR led OOH AUGIB service against the latest BSG National Audit results. Method We included adult patients (>16 years), presenting to LTHT between March and September 2016 with a suspected AUGIB having an endoscopy procedure performed by a SpR alone, SpR supervising SpR or SpR supervised by consultant. Baseline clinical, laboratory, demographic data, grade of endoscopist, place of endoscopy, findings of endoscopy and treatments applied were recorded. The primary outcome was 30 day all-cause mortality. Secondary outcomes were 60 and 90 day all-cause mortality, re-bleed rates and time to endoscopy. We used hazard ratios and multiple logistic regression analysis to examine the association between any of our collected variables, 30 day all-cause mortality and re-bleed rates. We classified a p-value of Results 177 patients (62% male, median age 67, range 18–97) were included in the study. 54% of endoscopies were performed by two SpRs, 41% by SpR alone and 5% by SpR supervised by a consultant. Median time to endoscopy was 16.3 hours and 22% were performed in theatre. 30, 60 and 90 day mortality were, 5.1%, 5.1% and 9.0% respectively with 8.9% patients having a re-bleed. Low baseline albumin predicted 30 day mortality: HR 1.25 (95% CI, 1.05–1.50) per 1 g/L drop. AIMS65, Blatchford, pre-endoscopy Rockall scores and other baseline laboratory tests were not statistically significantly associated with 30 day mortality or re-bleed rates, although there were few events. Conclusion An SpR-led OOH endoscopy rota compared favourably to national audit results for time to endoscopy, re-bleed and mortality. None of the prognostic scores demonstrated a statistically significant correlation with mortality rate. Where service configuration permits, the implementation of an SpR led AUGIB service may provide a model for exposure to training in AUGIB for Gastroenterology SpRs. Reference . Hearnshaw SA, Logan RFA, Lowe D, et al. Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK audit. Gut2011;60(10):1327–35 Disclosure of Interest None Declared
WavSTAT version 4 is an optical biopsy system designed for prediction of histology based on laser induced autofluorescence spectroscopy. The primary aim of this study was to demonstrate the accuracy of WavSTAT4 in characterising colorectal polyps <10 mm. The secondary aim was to compare the real time diagnostic performance of WavSTAT4 with NBI and a combination of endoscopic and WavSTAT assessments.
Methods
Adult patients referred for lower gastrointestinal endoscopy were included in the study. Patients with inflammatory bowel disease or colorectal cancer were excluded. Polyps sized <10 mm were assessed in real time by high definition white light, NBI and WavSTAT4 optical biopsy forceps. Histopathological specimens were read separately by two expert GI pathologists blinded to the results of the NBI and WavSTAT assessments.
Results
156 polyps were found in 70 patients (Males-44, females-27, average age 65). After applying exclusion criteria a total of 126 polyps <10 mm were included in the analysis. Wavstat4 had a NPV of 96.8% but lacked specificity. Endoscopic assessment had a NPV of 91% and was more specific. Since the specificity of WavSTAT was poor mainly for hyperplastic recto-sigmoid polyps we evaluated an algorithmic approach where we classified the polyps according to the WavSTAT4 result when proximal to the recto-sigmoid junction. We classed them according to the endoscopic classification if WavSTAT4 predicted an adenomatous polyp in the recto-sigmoid area. This combined algorithmic approach met the PIVI thresholds and had a NPV of 95.8% and predicted 100% of surveillance intervals correctly.
Conclusion
WavSTAT version 4 has a high NPV for characterising colorectal polyps less than 10 mm in size but only predicts surveillance intervals correctly in 81.2% of patients. . An algorithmic approach combining Wavstat4 and endoscopic assessment had a high NPV with accurate prediction of surveillance intervals.
Aims Endoscopic ultrasound guided choledochoduodenostomy (EUS-CDD) with electrocautery enhanced lumen apposing metal stents (EC-LAMS) has recently emerged as a viable option in the management of patients with malignant distal biliary obstruction (MDBO). We conducted a multi-centre collaboration from the UK and Ireland with an aim to analyse the pooled efficacy, safety and long term outcomes of EUS-CDD for treatment of MDBO.
EUS guided Fine Needle aspiration (FNA) is the standard of care for diagnosing solid pancreatic lesions. However, with personalised approach to oncological treatment histology is required to improve diagnostic accuracy and molecular characterisation. In a recent meta-analysis, the pooled sensitivity and specificity for EUS Fine Needle Biopsy (FNB) needle for diagnosing solid tumours is 84% and 99% respectively (1). A novel FNB needle has been introduced which has two sharp points of different lengths and it has a multifaceted bevel to capture additional tissue - Shark Core (SC). There has been limited data on this needle type. Our aim was to study the feasibility and efficacy of FNB-SC for diagnosing solid pancreatic and non-pancreatic lesions.
Method
We conducted a retrospective cohort study in which, all consecutive patients who had FNB-SC for solid tumours between July 2016 and January 2017, were identified through endoscopy database. The endoscopy reports, histology reports and Hepato-Pancreato-Biliary MDM outcomes were reviewed through hospital reporting systems. The histopathologist reviewed the tissue adequacy on all samples. We assessed the histological yield and diagnostic accuracy of the FNB-SC needle.
Results
29 patients were included in study of which, 55% (n=16) males and 45% (n=13) females with median age of 65 years (range 33–84). 26 patients (86%) had pancreatic lesions and 3 were non pancreatic lesions (2 GIST, 1 Ampullary adenoma). Median size of the lesions was 30 mm (range 17 mm-70mm). Sample deemed adequate for histological analysis in 96.5% (n=28) and inadequate in 3.5% (n=1). 22gauge needle was used in 86% and 25gauge in 14% of the patients. The Median number of passes to obtain adequate sample are 3 (range 2–4). Among the adequate samples obtained histological diagnosis were matched with radiological diagnosis in 89.2% (25/28) and with clinical diagnosis in 83% (24/28) at three months follow up with no further cancer detected. There was only one patient who had surgery in whom the histology results from surgical specimen matched with FNB diagnosis. The sensitivity, specificity, positive predictive value and negative predictive value for diagnostic accuracy were 92.8% (95% CI 76.5%>99.1%), 100% (95% CI 2.5%>100%), 100%, 33.3% (95% CI 11.6%–65.5%) respectively. There were no complications in our cohort of patients.
Conclusion
EUS FNB-SC needle is feasible and effective in obtaining tissue for solid tumours. It has high sensitivity and specificity in diagnosing solid tumours.
Reference
. Yang, Yongtao, et al. "Endoscopic ultrasound-guided fine needle core biopsy for the diagnosis of pancreatic malignant lesions: a systematic review and Meta-Analysis."Scientific reports6 (2016).
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