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ObjectiveEndoscopic resection (ER) often involves referral to tertiary centres with high volume practices. Lesions can be subject to prior manipulation and mischaracterisation of features required for accurate planning, leading to prolonged or cancelled procedures. As potential solutions, repeating diagnostic procedures is burdensome for services and patients, while even enriched written reports and still images provide insufficient information to plan ER. This project sought to determine the frequency and implications of polyp mischaracterisation and whether the use of telestration might prevent it.Design/methodA retrospective data analysis of ER referrals to four tertiary centres was conducted for the period July–December 2019. Prospective telestration with a novel digital platform was then performed between centres to achieve consensus on polyp features and ER planning.Results163 lesions (163 patients; mean age 67.9±12.2 y; F=62) referred from regional hospitals, were included. Lesion site was mismatched in 11 (6.7%). Size was not mentioned in the referral in 27/163 (16.6%) and incorrect in 81/136 (51.5%), more commonly underestimated by the referring centre (ConclusionsPolyp mischaracterisation is a frequent feature of ER referrals, but could be corrected by the use of telestration between centres. Our study involved expert-to-expert consensus, so extending to ‘real-world’ referring centres would offer additional learning for a digital pathway.

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

AIM Rectal neuroendocrine tumours (NETs) are the most common type of gastrointestinal NET. European Neuroendocrine Tumour Society guidelines suggest that rectal NETs measuring ≤10 mm are indolent with low risk of spread. In practice, many patients with lesions ≤1 cm do not undergo complete tumour staging. However, the size of the lesion may not be the only risk factor for nodal involvement/metastases. The aim of this study was to determine if MRI ± nuclear medicine imaging alters tumour stage in patients with rectal NETs ≤10 mm. METHODS Patients referred to a tertiary NET centre between 2005 and 2020 who met the inclusion criteria of a rectal NET ≤10 mm, full cross-sectional imaging, primarily an MRI scan and, if abnormal findings were identified, a subsequent 68 Ga-DOTATATE positron emission tomography scan were included. All patients were followed up at our institution. RESULTS In all, 32 patients with rectal NETs 10 mm or less were included in the study: 16 women; median age 58 years (range 33-71); 47% (n = 15) were referred from bowel cancer screening procedures. The median size of the lesions was 5 mm (range 2-10 mm). 81% (n = 26) were World Health Organization Grade 1 tumours with Ki67

Multimodal assessment of colorectal polyps is needed before decision-making for endoscopic mucosal resection or endoscopic submucosal dissection (ESD). Assessment should include morphology according to Paris classification, magnification endoscopy for vascular pattern, and Kudo pit pattern analysis. ESD should be offered to patients that have Vi pit pattern, lateral spreading tumors (LST) granular multinodular and LST nongranular, lesions with fibrosis and those in patients with inflammatory bowel disease. A defined strategy for resection and planning is crucial for successful and efficient resection with a clear audit of outcomes aiming for a perforation and bleeding rate of less than 1% and R0 resection greater than 90%.

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

Background Although peroral endoscopic myotomy (POEM) is highly effective for the management of achalasia, clinical failures may occur. The optimal management of patients who fail POEM is not well known. This study aimed to compare the outcomes of different management strategies in patients who had failed POEM. Methods This was an international multicenter retrospective study at 16 tertiary centers between January 2012 and November 2019. All patients who underwent POEM and experienced persistent or recurrent symptoms (Eckardt score > 3) were included. The primary outcome was to compare the rates of clinical success (Eckardt score ≤ 3) between different management strategies. Results 99 patients (50 men [50.5 %]; mean age 51.4 [standard deviation (SD) 16.2]) experienced clinical failure during the study period, with a mean (SD) Eckardt score of 5.4 (0.3). A total of 29 patients (32.2 %) were managed conservatively and 70 (71 %) underwent retreatment (repeat POEM 33 [33 %], pneumatic dilation 30 [30 %], and laparoscopic Heller myotomy (LHM) 7 [7.1 %]). During a median follow-up of 10 (interquartile range 3 – 20) months, clinical success was highest in patients who underwent repeat POEM (25 /33 [76 %]; mean [SD] Eckardt score 2.1 [2.1]), followed by pneumatic dilation (18/30 [60 %]; Eckardt score 2.8 [2.3]), and LHM (2/7 [29 %]; Eckardt score 4 [1.8]; P = 0.12). A total of 11 patients in the conservative group (37.9 %; mean Eckardt score 4 [1.8]) achieved clinical success. Conclusion This study comprehensively assessed an international cohort of patients who underwent management of failed POEM. Repeat POEM and pneumatic dilation achieved acceptable clinical success, with excellent safety profiles.

Introduction: Haemorrhage remains a major cause of morbidity and death in all surgical specialties. The aim of this study was to analyse the feasibility of PuraStat®, a new synthetic haemostatic device, made of self-assembling peptides in laparoscopic colorectal surgery.Material and methods: This was a prospective observational non-randomised study. Consecutive patients undergoing laparoscopic colorectal surgery were enrolled. Inclusion criterion was the need employ a secondary method of haemostasis when traditional methods such as conventional pressure or utilization of energy devices to control the bleeding were either insufficient or not recommended.Results: Twenty patients were enrolled. The mean time to apply the product was 40 secs (±17 secs), whereas the mean time to achieve haemostasis was 17.5 secs (±3.5 secs). There were no post-operative complications in this cohort of 20 patients. Mean operative time overall was 185 mins (±45.2 mins). None of the patients experienced delayed post-operative bleeding and the mean hospital stay was five days (±3,4).Conclusions: We demonstrated that PuraStat® can be easily used in laparoscopic surgery and it is a safe, effective haemostatic agent. This is a feasibility study and additional controlled studies would be useful in the future.

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

OverStitch devices (OverStitch and OverStitch Sx; Apollo Endosurgery, Inc, Austin, Tex, USA) are used for a wide range of applications. A European registry was created to prospectively collect technical and clinical data regarding both systems to provide procedural outcomes and to find correlation between procedural characteristics and outcomes. This study shows the initial results of the first 3 years of the registry.Patients who underwent endoscopic suturing from January 2018 to January 2021 at 9 centers were enrolled. Data regarding the disease treated,suturing pattern and outcomes were registered. Technical feasibility (success reaching the target area), technical success (success placing sutures), and clinical success (complete resolution of the clinical issue) were recorded and analyzed.During the study period, 137 patients (57.7% men) were enrolled with 100% technical feasibility rate. Endoscopic suturing was successfully performed in 136 cases (16.7% with OverStitch Sx), obtaining a technical success rate of 99.3%. No adverse events were recorded. Overall clinical success was 89%. Mucosal defects were sutured in 32 patients (100% clinical success). Leaks/fistulas were treated in 23 patients (64.7% clinical success). The clinical success of stent fixations (n = 38) was 85%. Perforations (n = 22) were repaired with a clinical success of 94.7%. No significant correlation between location, suture pattern or number, and the success was found, except in case of fistulas where fistulas 1 cm treated by a continuous suture were more likely to achieve clinical success in the follow-up (P .001).OverStitch-based suturing is technically feasible regardless of site and method of suturing, with no cases of failure. The overall technical success rate of 99.3% and the clinical outcome success rate of 89% demonstrate that OverStitch technology provides reliable suturing with clinical advantages, especially with fistulas 1 cm.

Main RecommendationThere is a need for well-organized comprehensive strategies to achieve good training in ESD. In this context, the European Society of Gastrointestinal Endoscopy (ESGE) have developed a European core curriculum for ESD practice across Europe with the aim of high quality ESD training.Advanced endoscopy diagnostic practice is advised before initiating ESD training. Proficiency in endoscopic mucosal resection (EMR) and adverse event management is recommended before starting ESD trainingESGE discourages the starting of initial ESD training in humans. Practice on animal and/or ex vivo models is useful to gain the basic ESD skills. ESGE recommends performing at least 20 ESD procedures in these models before human practice, with the goal of at least eight en bloc complete resections in the last 10 training cases, with no perforation. ESGE recommends observation of experts performing ESD in tertiary referral centers. Performance of ESD in humans should start on carefully selected lesions, ideally small ( Endoscopists performing ESD should be able to correctly estimate the probability of performing a curative resection based on the characteristics of the lesion and should know the benefit/risk relationship of ESD when compared with other therapeutic alternatives. Endoscopists performing ESD should know how to interpret the histopathology findings of the ESD specimen, namely the criteria for low risk resection (“curative”), local risk resection, and high risk resection (“non-curative”), as well as their implications. ESD should be performed only in a setting where early and delayed complications can be managed adequately, namely with the possibility of admitting patients to a ward, and access to appropriate emergency surgical teams for the organ being treated with ESD.

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

Background Histopathological features associated with coexistent invasive adenocarcinoma in large colorectal adenomas have not been described. This study aimed to determine the association of histopathological features in areas of low-grade dysplasia with coexistent invasive adenocarcinoma. Methods High-grade lesions (containing high-grade dysplasia or adenocarcinoma) from a cohort of large (at least 20 mm) colorectal adenomas removed by endoscopic resection were subjected to detailed histopathological analysis. The histopathological features in low-grade areas with coexistent adenocarcinoma were reviewed and their diagnostic performance was evaluated. Results Seventy-four high-grade lesions from 401 endoscopic resections of large adenomas were included. In the low-grade dysplastic areas, a coexistent invasive adenocarcinoma was associated significantly with a cribriform or trabecular growth pattern (P, Histopathological features associated with coexistent invasive adenocarcinoma in large colorectal adenomas have not been described. This study found several histopathological features identified in low grade areas of large adenomas were predictive of the presence of coexistent invasive cancer elsewhere in the lesion. An increasing number of these features is a strong predictor of coexistent invasive adenocarcinoma with an AUROC of 0.92 and ≥2 of these adverse histopathological features in low-grade areas had a sensitivity of 86% and specificity of 84% for coexistent invasive adenocarcinoma.

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

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

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

BACKGROUND The technical evolution of hernia repair has brought to the introduction of laparoscopy in this field. The most common laparoscopic techniques are transabdominal preperitoneal (TAPP) repair and totally extraperitoneal (TEP) repair. Indirect comparisons between TAPP and TEP have raised questions as to which is the superior approach in improving patient outcomes; however, there is still a scarcity of data directly comparing these laparoscopic approaches. The aim of this report is to offer a retrospective comparison between the two techniques with a long-term follow-up. METHODS This study is a retrospective comparative study, comparing TEP and TAPP in the treatment of groin hernias. All patients undergoing laparoscopic hernia repair from 2015 and 2020 at a large UK Hospital Trust with tertiary referral center, were considered as eligible for inclusion. The primary endpoint was rate of successful surgery defined as absence of recurrence and chronic pain at the end of the follow-up. Secondary endpoints were conversion rate (the switch from TEP to TAPP was considered as a conversion for the index procedure), need for admission, readmission rate, serious adverse events (including visceral injuries and vascular injuries), rate of persisting pain at the end of follow-up, operative time and overall complications rate (hematoma, seroma, wound/superficial infection, mesh/deep infection, port site hernia). RESULTS Of the patients included in the study who underwent laparoscopic repair of inguinal hernia between 2015 and 2020, 140 (55.1%) underwent TEP and 114 (44.9%) had TAPP repair. The mean operative time did not differ between the two groups (P=0.202). The conversion rate was nil. The two procedures did not differ for intraoperative and postoperative complications. The length of hospital stay was significantly longer in the TAPP group (P

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

Haemorrhage remains a major cause of morbidity and death in all surgical specialties. The aim of this study was to analyse the feasibility of PuraStatThis was a prospective observational non-randomised study. Consecutive patients undergoing laparoscopic colorectal surgery were enrolled. Inclusion criterion was the need employ a secondary method of haemostasis when traditional methods such as conventional pressure or utilization of energy devices to control the bleeding were either insufficient or not recommended.Twenty patients were enrolled. The mean time to apply the product was 40 secs (±17 secs), whereas the mean time to achieve haemostasis was 17.5 secs (±3.5 secs). There were no post-operative complications in this cohort of 20 patients. Mean operative time overall was 185 mins (±45.2 mins). None of the patients experienced delayed post-operative bleeding and the mean hospital stay was five days (±3,4).We demonstrated that PuraStat

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

Background and study aims Decisions concerning additional surgery after endoscopic resection of T1 colorectal cancer (CRC) are difficult because preoperative prediction of lymph node metastasis (LNM) is problematic. We investigated whether artificial intelligence can predict LNM presence, thus minimizing the need for additional surgery. Patients and methods Data on 690 consecutive patients with T1 CRCs that were surgically resected in 2001 – 2016 were retrospectively analyzed. We divided patients into two groups according to date: data from 590 patients were used for machine learning for the artificial intelligence model, and the remaining 100 patients were included for model validation. The artificial intelligence model analyzed 45 clinicopathological factors and then predicted positivity or negativity for LNM. Operative specimens were used as the gold standard for the presence of LNM. The artificial intelligence model was validated by calculating the sensitivity, specificity, and accuracy for predicting LNM, and comparing these data with those of the American, European, and Japanese guidelines. Results Sensitivity was 100 % (95 % confidence interval [CI] 72 % to 100 %) in all models. Specificity of the artificial intelligence model and the American, European, and Japanese guidelines was 66 % (95 %CI 56 % to 76 %), 44 % (95 %CI 34 % to 55 %), 0 % (95 %CI 0 % to 3 %), and 0 % (95 %CI 0 % to 3 %), respectively; and accuracy was 69 % (95 %CI 59 % to 78 %), 49 % (95 %CI 39 % to 59 %), 9 % (95 %CI 4 % to 16 %), and 9 % (95 %CI 4 % – 16 %), respectively. The rates of unnecessary additional surgery attributable to misdiagnosing LNM-negative patients as having LNM were: 77 % (95 %CI 62 % to 89 %) for the artificial intelligence model, and 85 % (95 %CI 73 % to 93 %; P Conclusions Compared with current guidelines, artificial intelligence significantly reduced unnecessary additional surgery after endoscopic resection of T1 CRC without missing LNM positivity.

Background and study aims The variables associated with gastroesophageal reflux (GER) after peroral endoscopic myotomy (POEM) are largely unknown. This study aimed to: 1) identify the prevalence of reflux esophagitis and asymptomatic GER in patients who underwent POEM, and 2) evaluate patient and intraprocedural variables associated with post-POEM GER. Patients and methods All patients who underwent POEM and subsequent objective testing for GER (pH study with or without upper gastrointestinal [GI] endoscopy) at seven tertiary academic centers (one Asian, two US, four European) were included. Patients were divided into two groups: 1) DeMeester score ≥ 14.72 (cases) and 2) DeMeester score of Results A total of 282 patients (female 48.2 %, Caucasian 84.8 %; mean body mass index 24.1 kg/m2) were included. Clinical success was achieved in 94.3 % of patients. GER evaluation was completed after a median follow-up of 12 months (interquartile range 10 – 24 months). A DeMeester score of ≥ 14.72 was seen in 57.8 % of patients. Multivariable analysis revealed female sex to be the only independent association (odds ratio 1.69, 95 % confidence interval 1.04 – 2.74) with post-POEM GER. No intraprocedural variables were associated with GER. Upper GI endoscopy was available in 233 patients, 54 (23.2 %) of whom were noted to have reflux esophagitis (majority Los Angeles Grade A or B). GER was asymptomatic in 60.1 %. Conclusion Post-POEM GER was seen in the majority of patients. No intraprocedural variables were identified to allow for potential alteration in procedural technique.

Background/Aim: Total mesorectal excision combined with neo-adjuvant chemoradiotherary (CRT) and adjuvant chemotherapy, has been the standard treatment of locally advanced rectal cancer (LARC). Although TNM (Tumor, Node, Metastasis) classification for malignant Tumors is still the cornerstone in rectal cancer staging, there has been an effort to identify molecular biomarkers with additional prognostic or predictive value. Materials and Methods: We retrospectively analyzed molecular biomarkers on prospectively collected histological specimens and clinical data from a cohort of 135 consecutive rectal cancer cases who underwent radical excision in a tertiary center between 2011-2014 (males=87, females=48, age range=22-89 years, mean=64,67 years, SD=13.40). Radiological, histopathological, molecular staging, treatment stratification by the multidisciplinary team (MDT), as well as prognostic outcome data were compared with various biomarkers including KRAS, BRAF, p16, b-catenin, MSI, MMR and MGMT. Results: The mean follow-up was 39.21 months (range=5-83 months, SD=21.34). Twenty-eight cases were Stage I (20.9%), n=30 Stage II (22.4%), n=45 Stage III (33.6%) and n=31 Stage IV (23.1%). Forty specimens were KRAS-mutant (mt) (37.4%) while n=67 (62.6%) wild type (wt). KRAS mt status was associated with female sex (n=20, p=0.021) and older age (69.62 vs. 62.27, p=0.005). Stage I Early Cancer Subgroup analysis showed that KRAS mt status is associated with distant recurrence of disease (n=4, p=0.045). Conclusion: KRAS mt status may affect the prognosis of early rectal cancer, as this is linked with distant recurrence.

Symptomatic diverticular disease (DD) is a major worldwide healthcare burden, and diverticular bleeding is one of its most common manifestations. Endoscopic clipping of selected diverticula in the acute or early posthaemorrhage period has been reported as a haemostatic intervention, but the effect of elective clipping is not known. We present the prospective series of elective endoscopic clipping with the aim of treating all visible diverticula in patients with previous bleeding, resulting in near-complete disappearance of DD. This may have significant implications for the management of DD worldwide and warrants further prospective research. This was a prospective, single-centre study enrolling consecutive patients attending a specialist DD clinic at our institution, who had been previously hospitalised for lower GI bleeding due to DD (table 1). The procedures and follow-up colonoscopies were carried out from April 2015 to April 2017 at King’s College Hospital, London, UK. Patients with other GI pathologies were excluded from the study. View this table: Table 1 Episodes of confirmed diverticular bleeding requiring transfusion and hospitalisation before the procedure and in 1 year of follow-up Patients were enrolled only if the diagnosis had been confirmed by abdominopelvic CT scan and full colonoscopy during an episode of PR bleeding. The results and management plan were discussed in a multidisciplinary team meeting with informed consent from the patients. Any patients requiring previous admissions and transfusion for confirmed severe diverticular bleeding were included in the study. Patients underwent colonoscopy after full oral bowel preparation (Moviprep, Norgine Pharmaceuticals) under conscious sedation with midazolam and fentanyl. On withdrawal of the colonoscope (Olympus CF-H260DL or CF-H260AZL), all visible diverticula were carefully cleaned of residual stool using water delivered through the working channel …

Objectives: Recently, several studies have demonstrated the usefulness of endoscopic submucosal dissection (ESD) for residual or locally recurrent colorectal lesions after endoscopic treatment. However, the feasibility of ESD for recurrent rectal lesions after transanal endoscopic microsurgery (TEM) has not been fully investigated. In this study, we evaluated the feasibility and safety of ESD for recurrent rectal lesions after TEM. Methods: The treatment outcomes of 10 lesions in 9 patients, who underwent ESD between January 2006 and March 2018 for recurrent rectal lesions after transanal endoscopic microsurgery, were evaluated. Results: All lesions were successfully resected en bloc, and the R0 resection rate was 90%. The median size of the resected specimens and lesions (range) was 44 mm (21–70) and 27.5 mm (5–60), respectively. The pathological diagnoses included 4 adenomas and 6 cancerous lesions. The cancerous lesions included 5 cases of mucosal cancer and 1 case of superficial submucosal invasive cancer (depth of submucosal invasion Conclusions: ESD for recurrent rectal lesions after TEM by expert’s hands appears to be safe and feasible.

Introduction Current literature estimates that complete endoscopic resection (ER) of duodenal adenomas can be achieved in 79–100% of cases, but complication rates are high and adenoma recurrence is encountered in up to 37% of cases (Basford & Bhandari, 2012). We present our retrospective experience. Methods Data from the electronic patient record was analysed for all patients who underwent duodenal polyp resection from June 2013 were included (excl. familial polyposis cases). Procedures were performed by either one of two endoscopists with experience in endoscopic resection. Accepted definitions of technical success, major adverse events and recurrence were used. Results 31 patients (15F; mean age 67.9± 10.4 y) were included. The mean polyp size was 38.8±23.6 mm, with most (n = 26) located within D2. More than half were laterally spreading lesions (n=16). The main method of resection was with piecemeal EMR (n=24), with 5 removed by en-bloc EMR and 2 by ESD. Histology revealed tubular adenoma low grade dysplasia (n = 12), tubulovillous adenoma with low grade dysplasia (n = 11) and neuroendocrine tumour (n = 3). ER was successful in 28/31 cases (90.3%). Mean size in 3 incomplete resections was 93 mm, with 1 patient referred for surgery, 1 repeat ER and 1 did not proceed due to a more pressing medical diagnosis. 3/31 had peri-procedural complications: endoscopically-treated perforation in 2 (6%) and minor bleeding in 1. 2/31 patients (6%) experienced delayed bleeding, with one patient requiring a repeat OGD but no intervention and the other requiring transfusion of packed red blood cells and observation in hospital. There was no procedure related mortality. At time of writing 4 patients had not yet had surveillance OGD and to date 5 patients (20.8%) had recurrence all treated endoscopically. Conclusion ER of duodenal polyps is feasible and safe. Our single centre experience is on par with what is published in the literature in regards to technical success and adverse events. A prospective analysis would be of value to guide patient selection, optimal treatment and surveillance protocols.

Introduction Gastro-oesophageal reflux disease(GORD) is a common condition carrying an arduous process for diagnosis. Symptom questionnaires and proton-pump inhibitor challenge lack reliability and white light endoscopy (WLE) is often normal. Objective measurement of oesophageal acid exposure time (AET) require invasive testing. Changes in intrapapillary capillary loops (IPCLs) identified using narrow band imaging(NBI) have been proposed as a marker for reflux. We evaluated a near focus (NF-NBI) driven artificial intelligence(AI) model for the diagnosis of GORD. Methods Patients with symptoms of GORD (recorded using the Reflux Disease Questionnaire(RDQ)) were prospectively recruited over 10 months. Upper endoscopy recorded multiple NF-NBI images, video and biopsies of the lower oesophagus. If endoscopy using High-Definition WLE was normal, a pH-recording capsule was placed. Patients were defined according to Lyon criteria; Erosive oesophagitis(EO);non-erosive reflux disease(NERD);functional heartburn(FH). Two forms of AI were developed and evaluated to automate regions of interest (ROI) and detect IPCLs and morphology: computer vision (CV) and deep convoluted neural network(DCNN) using Resnet50. DCNN was evaluated using training: unseen testing dataset ratios of 50:50 (3872:4280 images) and 75:25 (6484:1668 images). For the purposes of training the AI models, EO and NERD cases were combined as ‘GORD’. A novel combined classifier (CC) of both AI methods was evaluated. Results 78 consecutive patients were recruited. n=68 (46 Female, 44.41±12.91 years): GORD n=27 (EO n=6, NERD n=21) and FH n=41 were analysed. The mean IPCL per ROI count was greater in GORD vs FH: 33.2 ± 5.19 vs 28.1 ± 5.42 p=0.0003 and was used as the primary diagnostic tool. IPCL morphology for GERD vs FH: length 16.29 vs 16.98, p=0.19; width 7.8 vs 7.8, p=0.98; red 118.8 vs 120.6, p=0.44; green 114.3 vs 118, p0.004; blue 94.24 vs 97.54 p=0.07. With CV: mean IPCLs/ROI (threshold 27.6) had sensitivity, specificity, AUC: 88.9, 58.5, 0.76 (p=0.0003) for GORD. With DCNN 50:50 these results were 58%, 86% and 76% respectively. DCNN 75:25 produced 67%, 92%, 83% respectively. CC improved overall specificity(89.1%) and accuracy(78.1%) but not sensitivity(63%). Conclusion AI using NF-NBI is a novel method for the diagnosis of GORD. With increased data, improvements in diagnostic accuracy is achieved further improved using a CC. This model has the potential to provide a reliable safe single-test diagnosis of GORD.

Introduction Resection of large rectal adenomas by TEM or endoscopic resection (ER) varies by institution and region. There is a paucity of data directly comparing these strategies and the procedure of choice remains under intense debatable. We report outcomes of TEM and ER of large rectal adenomas from a large tertiary cohort. Methods Large (≥20 mm) rectal adenomas resected by TEM or ER (2009–2018) were analysed. From 2009–2011 all rectal adenomas were treated by TEM, after which the primary resection strategy changed to ER. Outcomes were compared between techniques. Results 258 rectal adenomas were resected by TEM (n=73), EMR (n=61) and ESD/Hybrid ESD (n=124) with a mean size of 46 mm for TEM vs 62 mm for ER (p Conclusion Despite significantly larger lesion sizes, ER in our institution provides far superior results for patients than TEM with relatively few patients requiring general anaesthesia or hospital admission and lower recurrence rates especially with ESD. This has led to a policy of ER for all apparently benign rectal tumours regardless of size and, more recently, an ESD-first approach for all lesions.

Introduction ESD is rarely practiced in western centres. Given its technical difficulty, many western experts believe indications for ESD are limited. However, histopathologic diagnostic and treatment uncertainty resulting in over- or under-treatment can have grave consequences in the rectum. As a result, our unit recently opted for the exclusive use of ESD/Hybrid ESD to resect all large rectal adenomas. We report short term outcomes using this protocol for 12 months. Methods Endoscopic resection (ER) of large (≥20 mm) colorectal adenomas were analysed and outcomes compared after adoption of an exclusive ESD resection strategy for all rectal adenomas ≥20 mm for 12 months (Period 2) compared to earlier resections (Period 1) when resection strategy was based on lesion morphology, surface characteristics and ER experience. Results ER was performed for 185 rectal adenomas (period 1 n=154, Period 2 n=31) with a mean size of 63 mm (range 20–160 mm). ESD/Hybrid ESD was used for 97% of ER in Period 2 versus 61% in Period 1 (p Conclusions ESD/Hybrid ESD for all large rectal adenomas, even when incorporating ESD training, is feasible and safe with sufficient expertise and experience. Data for long term outcomes are desirable to evaluate potential benefits in oncological results, reduced recurrence and potential fewer additional procedures.

Introduction Safe and effective endoscopic resection (ER) relies on the endoscopic diagnosis of large lesions to predict the risk of invasive cancer. However, a detailed evaluation of histopathological features and the molecular profile of the polypoid dysplastic mucosa to predict coexistent invasive neoplasm is not available. Methods: Data from endoscopic resection of colorectal superficial neoplastic lesions performed at a UK tertiary referral center (2011-2016) were analyzed. Lesions were assessed using magnification chromoendoscopy and narrow band imaging. A subset of these lesions containing high-grade dysplasia, intramucosal cancer or invasive cancer was identified and further subjected to a detailed histopathological analysis: endoscopic type, ulceration, distribution of high-grade dysplasia, dysplastic nuclear grade, presence and distribution of necrosis, and distribution of tumor-infiltrating lymphocytes (TIL). The two areas with the highest morphological grade were microdissected from each lesion, using 5μm FFPE sections. DNA extraction and next-generation sequencing using a human clinically relevant tumor panel (Qiagen, Hiden, Germany) of 24 genes were performed for each of these areas separately. Genetic abnormalities for each locus were categorized by genetic impact according to its severity (low/moderate/high/modifier) and allele frequency. Results: ER was performed for 418 large (≥20mm) colorectal superficial neoplastic lesions (mean size 55.2mm, range 20mm-160mm), 81% being laterally spreading tumors (LST). The proportions harboring an area of invasive cancer by morphological subtype were as follows: LST non-granular 30.8%; LST granular mixed-nodular type 12.3%; LST granular homogeneous type 0.9% and Is/Isp 11.4%. The histopathological genetic evaluation was available in 70 cases; a coexistent adenocarcinoma significantly correlated with dysplastic adenomatous mucosa featuring ulceration, mixed interface/interstitial TIL, multifocal high nuclear grade, infiltrative edges, and multifocal intraluminal necrosis. Multifocal intraluminal necrosis and high nuclear grade in the adjacent low-grade dysplastic mucosa were driven by cooperative genetic abnormalities of high-impact (FLT4), moderate impact (KRAS/NRAS for infiltrative edges, FLT4, TP53, ERBB2), and low impact (FGFR3, PDGFA). Conclusions The dysplastic stage of high-grade adenomatous polyps is characterized by multiple cooperative genetic mutations. A subset of these markers identify a risk of coexistent adenocarcinoma with a close correlation between genetic markers of angiogenesis (FLT4), receptor activation (RAS/ERBB2), genome maintenance (TP53) and stromal reaction (FGFR3, PDGFRA) with morphological features defined by high nuclear grade, intraluminal necrosis, and inflammatory stromal reaction.

Introduction There are no agreed endoscopic signs for the diagnosis of villous atrophy(VA) in coeliac disease(CD), necessitating biopsies and for both diagnosis and exclusion. Here we evaluated the role of near focus Narrow Band Imaging(NF-NBI) for the assessment of villous architecture in suspected CD with development and further validation of a novel NF-NBI classification. Methods Patients with symptoms/investigations warranting duodenal biopsy were prospectively recruited between September 2017 to August 2018. Six paired NF-white light(NF-WLE) and NF-NBI images with biopsy (2 from the first part of the duodenum,4 from the second) were obtained from each patient. Histopathology grading used Marsh-Oberhuber classification(M-O). Images were reviewed for quality and biopsy orientation. Separate images were used for development of the classification, training and validation steps. A modified Delphi process was performed on images and video recordings by 3 endoscopists to define NF-NBI characteristics(included if kappa>0.6). 13 blinded endoscopists(5 expert, 8 non-expert) underwent a short training module on the proposed NBI classification and evaluated paired(NF-WLE/NF-NBI) images. Results 100 consecutive patients were recruited and n=97 completed the study (66F, 51.2±17.3 yrs). TTG positive n=17/89. Prevalence of M-O VA(3a/3b/3c) in D1 and D2 biopsies was 52/194(27%) and 70/388(18%) respectively. After image quality and biopsy orientation review; 548 paired images remained. 498 paired images developed the classification; 3 descriptors:Villous shape, vascular discrimination, crypt phenotype proposed the classification. 13 endoscopists evaluated 50 paired images each(D1:20, M-O 0:26, M-O 3a-3b:13, M-O 3c:11). Pooled diagnostic test summary statistics(%) for NF-NBI diagnosis of VA(Subtotal/total atrophy) were: Sensitivity 97.9(91.67–100), specificity 82.15(62.5–100), NPV 97.7(92.59–100) and accuracy 89.7(80–96) respectively. Mean difference in confidence using NF-NBI vs NF-WLE significantly improved when assessing the first part duodenum: The classification was further validated in histopathologically proven duodenitis(n=15) images with no features of VA using the proposed classification. Conclusion A novel NF-NBI classification for VA had been validated to reliably diagnose VA in suspected CD amongst both expert/non-expert endoscopists using readily available equipment and required only short training supporting translation to wider practice.

Introduction Safe sedation practice is a recognised cornerstone of high-quality endoscopy. There are concerns that local anaesthetic throat spray (TS) in combination with intravenous sedative and analgesic agents (ISAAs) can precipitate respiratory complications, specifically, aspiration pneumonia. Current BSG standards for upper gastrointestinal endoscopy recommend ‘caution should be exercised’ in using agents combined with TS but acknowledges the paucity of evidence for this, with the few relevant studies being performed several decades ago. Methods A retrospective, two-centre cohort study was performed. Only diagnostic, outpatient gastroscopies (OGDs) performed 2013–2018 were reviewed. Patients residing in a postcode region (definite or possible) outside of the catchment of the two centres were excluded from final analysis. Endoscopy reports and electronic patient records were reviewed to identify all patients who presented to hospital within 30 days of their procedure to determine the underlying reason for this. Results 5,803 OGDs met the inclusion criteria. 148 (2.6%) patients presented to hospital within 30 days of procedure, 17 (0.3%) were due to potential respiratory complications (pneumonia, respiratory tract infection and infective exacerbation of COPD). Choice of drug included: TS 3163 (54.5%); TS+midazolam 1508 (26%); TS+fentanyl 28 (0.5%); TS+dual agent 382 (6.6%) and non-TS 722 (12.4%). Only TS and TS+analgesic/sedative groups were compared. There was no significant difference in the rate of respiratory complications between the two groups (p=1.0, two-sided Fisher’s Exact Test). 12/17 respiratory complications occurred in the TS group. Procedure discomfort scores were similar in this group when compared to the TS and additional agent group. Conclusions While safe sedation practice should remain the cornerstone of management and clinicians should continue to exercise caution in patients with respiratory comorbidities, inpatients and therapeutic procedures, the combination of TS+ISAAs does not increase the risk of respiratory complications following elective diagnostic OGD.

Introduction Per-oral endoscopic myotomy (POEM) has gained acceptance as an effective treatment for achalasia and other oesophageal motility disorders but may not be seen as a ‘first-line’ intervention. Many patients referred for POEM to our institution had, therefore, undergone other therapies and little is known about the influence of this or other factors on treatment outcomes. This study provides an overview of treatment success and safety from our institution. Methods All patients undergoing POEM since 2013 have been recorded in a registry for baseline characteristics: demographic data, disease classification, previous treatments, manometry, symptoms scores, length of stay (LOS) and procedure parameters. Treatment success was defined as Eckardt score ≤3 and/or reduction by 4 points. Following POEM patients underwent periodic follow-up assessment for: symptoms scores, manometry+pH studies and complications. Results 103 procedures were performed (98 achalasia, 5 other motility disorders; median disease duration 3.0 y (range 0.3 – 25.0), 46(44.2%) with prior therapy. Median procedure time was 75 min and LOS 2 nights. Success was achieved in 82/91 procedures (90.1%) at 3 months, with significant improvement in median Eckardt scores (8 vs 1, p Conclusions POEM is an effective and safe treatment modality for achalasia and other oesophageal motility disorders. Treatment success is affected by previous myotomy and may be influenced by duration of disease and previous other therapies, making a case for earlier intervention. To better understand predictors of outcome, patient selection factors and long-term outcomes we will be implementing a European registry for POEM to guide referrers and practitioners.