Post-DDW OAG Course - Therapeutic Endoscopy

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1 Post-DDW OAG Course - Therapeutic Endoscopy June 13, 2015 Jeffrey Mosko Division of Gastroenterology St. Michael's Hospital University of Toronto

2 Program Name: Post-DDW OAG course CanMEDS Roles Covered in this Session:! Medical Expert (as Medical Experts, physicians integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centered care. Medical Expert is the central physician Role in the CanMEDS framework.) Communicator (as Communicators, physicians effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter.) Collaborator (as Collaborators, physicians effectively work within a healthcare team to achieve optimal patient care.) Manager (as Managers, physicians are integral participants in healthcare organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the healthcare system.) Health Advocate (as Health Advocates, physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations.) Scholar (as Scholars, physicians demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge.) Professional (as Professionals, physicians are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour.)

3 Name: Dr. Jeffrey Mosko Financial Interest Disclosure (over the past 24 months) No relevant financial relationships with any commercial interests

4 Outline 1. Barrett s/emr Hot avulsion in BE (Tu1573) 2. Colon/EMR Water Immersion EMR (725) Prophylactic clips after EMR (330) 3. Gastric varices EUS guided therapy for fundal varices (209)

5 Outline 1. Barrett s/emr Hot avulsion in BE (Tu1573) 2. Colon/EMR Water Immersion EMR (725) Prophylactic clips after EMR (330) 3. Gastric varices EUS guided therapy for fundal varices (209)

6 Hot Avulsion Endoscopic Mucosal Resection (EMR) = standard of care for the management of colorectal, laterally spreading tumours (LST) Residual rates 1-14% Higher in larger polyps Ablative techniques reserved for portions that are resistant to snaring APC Snare-tip cautery (soft coag) Luigiano et al. Endoscopy 2009 Verrappan et al. GIE 2015

7 Hot Avulsion Hot avulsion technique (Haber DDW 2014) Hot biopsy forceps Slight tension Endocut (tapping) Verappan et al. GIE patients undergoing HA for non-lifting areas 20/20 successful 15% recurrence No immediate/long-term AEs Luigiano et al. Endoscopy 2009 Verrappan et al. GIE 2015

8 Hot Avulsion

9 Tu1573 Hot Avulsion Provides a Second Chance At Completing Barrett s Eradication Background Barrett s + dysplasia requires complete eradication of metaplastic columnar mucosa Objective Analyze the efficacy and safety of hot avulsion in this setting Methods Prospective, single centre, n = 18 All patients undergoing routine f/u after undergoing endoscopic Tx of BE-related dysplasia No raised lesions Islands/tongues < 1cm Hot avulsion only Aranda-Hernandez et al. DDW 2015

10 Tu1573 Hot Avulsion Provides a Second Chance At Completing Barrett s Eradication Aranda-Hernandez et al. DDW 2015

11 Tu1573 Hot Avulsion Provides a Second Chance At Completing Barrett s Eradication White light NBI Post injection Post-avulsion Aranda-Hernandez et al. DDW 2015

12 Tu1573 Hot Avulsion Provides a Second Chance At Completing Barrett s Eradication Conclusions: Effective, safe and diagnostically useful for eradication of small residual BE areas after first line therapies for BE dysplasia Larger controlled studies needed Aranda-Hernandez et al. DDW 2015

13 Outline 1. Barrett s/emr Hot avulsion in BE (Tu1573) 2. Colon/EMR Water Immersion EMR (725) Prophylactic clips after EMR (330) 3. Gastric varices EUS guided therapy for fundal varices (209)

14 Colon/EMR Concerns Co-existing malignancy Incomplete resection/recurrence Safety Bleeding Perforation

15 Colon/EMR

16 Colon/EMR

17 Colon/EMR Incomplete resection/recurrence Khashab et al. GIE studies Mean recurrence rate = 26% Pohl et al. - CARE study Gastro 2013 Incomplete resection 7-23% Risk factors: Size Flat Piecemeal resection [Prior biopsy - Moss et al., Gastro 2011]?submucosal injection

18 What about submucosal injection?

19 Underwater EMR

20 725 Water Immersion Technique Polypectomy for Large Sessile Colorectal Polyps Retrospective, single centre, All UEMR Outcomes: Feasibility Safety Effectiveness Results N = 72 polyps removed via UEMR Sandhu et al. DDW 2015

21 725 Water Immersion Technique Polypectomy for Large Sessile Colorectal Polyps N=72 polyps Mean polyp size 21.2 ± 9.2mm Location Right 74% Left 12% Rectum 14% Piecemeal resection 86% Prophylactic clipping 71% Delayed bleeding 10% Recurrence Other complication (infection, perforation, death) 10% (all successfully removed) 0% Sandhu et al. DDW 2015

22 Underwater EMR Conclusion: safe & effective technique

23 Colon/EMR Bourke et al. ACE resection study group Now >2500 patients Intra-procedural bleeding 10% Post-EMR bleeding 6-7% 10-12% right colon

24 330 Prophylactic Clipping Strategy Is Not Cost Effective Following WF-EMR Background Wide-field endoscopic mucosal resection (WF- EMR) is an effective strategy for large sessile and laterally spreading colorectal lesions Clinically significant post EMR bleeding (CSPEB) = most common adverse event 6-12% in proximal colon High morbidity and resource utilization No proven therapies to prevent CSPEB Bahin et al. DDW 2015

25 330 Prophylactic Clipping Strategy Is Not Cost Effective Following WF-EMR Objective: Determine cost-effectiveness of a prophylactic clipping strategy for the prevention of CSPEB Methods: Economic modeling study ACE study Prospective, observational WF-EMR of LSL >20mm procedure, 14d (telephone), 4mo - surveillance colon CSPEB = bleeding post-procedure requiring ER visit, admission or repeat intervention Bahin et al. DDW 2015

26 330 Prophylactic Clipping Strategy Is Not Cost Effective Following WF-EMR Results 1717 lesions mean size 35.8mm 52.5% prox colon CSPEB rate 6.4% Proximal 8.9% Distal 3.7% 45% required endoscopic management Bahin et al. DDW 2015

27 330 Prophylactic Clipping Strategy Is Not Cost Effective Following WF-EMR Bahin et al. DDW 2015

28 330 Prophylactic Clipping Strategy Is Not Cost Effective Following WF-EMR Bahin et al. DDW 2015

29 330 Prophylactic Clipping Strategy Is Not Cost Effective Following WF-EMR Bahin et al. DDW 2015

30 330 Prophylactic Clipping Strategy Is Not Cost Effective Following WF-EMR Bahin et al. DDW 2015

31 330 Prophylactic Clipping Strategy Is Not Cost Effective Following WF-EMR Conclusion: Funds needed to spend to prevent 1 CSPEB = $16,000 overall $33,000 distal colon $10,000 proximal colon Selective clipping strategy cheaper but still 4x > not clipping Clip price of $11.50 would result in costequivalence Bahin et al. DDW 2015

32 Outline 1. Barrett s/emr Hot avulsion in BE (Tu1573) 2. Colon/EMR Water Immersion EMR (725) Prophylactic clips after EMR (330) 3. Gastric varices EUS guided therapy for fundal varices (209)

33 Gastric Varices Sarin et al. Hepatology 1992

34 EUS-guided coil +/- glue

35 209 EUS-guided treatment of gastric fundal varices with combined injection of coils and glue Aim: Evaluate long-term efficacy, safety and outcomes of EUS guided therapy of GFV with combined coil and CYA injection Methods Retrospective, single centre, Inclusion: Active/recent GV bleed High risk primary prophylaxis (GV >2cm on EUS) Bhat et al. DDW 2015

36 209 EUS-guided treatment of gastric fundal varices with combined injection of coils and glue Bhat et al. DDW 2015

37 209 EUS-guided treatment of gastric fundal varices with combined injection of coils and glue Bleeding at index procedure Active 5% Hx bleeding or 69% stigmata Re-bleeding Primary prophylaxis 26% Overall 8% Treatment additional coil/glue TIPS splenectomy IR splenic embolization 4% <2% <2% Adverse Events (n=124) <1% PE 1 Pain 4 Minor bleeding 4 Bhat et al. DDW 2015

38 209 EUS-guided treatment of gastric fundal varices with combined injection of coils and glue Conclusions: Highly effective for hemostasis Active bleeding Primary + secondary prophylaxis Low risk re-bleeding Safe May reduce/eliminate risk of clinical relevant CYA embolization Bhat et al. DDW 2015

39 QUESTIONS???

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