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Colorectal cancer (CRC) is the second most frequent cause of cancer-related death in Western countries: one third of CRC is represented by rectal cancer (RC). Accurate staging is recommended to provide an optimal treatment strategy. Neoadjuvant chemoradiotherapy (NCRT) is increasingly used in the treatment of advanced RCwith the intention of downsizing and downstaging the tumour and to reduce tumour recurrence. Accuracy of EUS staging is reported to be 75-94% for tumour penetration and 7283% for nodal metastases. However after NCRT the EUS accuracy for T staging may decrease (50%) because marked fibrosis, peritumoral infiltration of inflammatory cell necrosis. AIMS: the aims of this study was to verify the accuracy of EUS in restaging RC after neoadjuvant CRT and the efficacy of the therapy in the downstaging and downsizing the tumour. METHODS: we prospectively enrolled consecutive patients affected by RC in stage II-b and III who underwent EUS and MRI or CT or PET before and after neoadjuvant CRT. EUS scanning was performed by one endosonographer using an electronic radial ecoendoscope (Olympus GF UE 160-AL5) with imaging at 7,5-10 MHz. Patients underwent surgical resection after reassessment staging. The reduction of diameter of RC was evaluated using RECIST criteria. Pathological staging was undertaken according to the TNM classification. RESULTS: 14 patients with locally advanced RC were assessed: 10 male, median age 64 yrs (range 56-73). The median distance from the anus was 5 cm. Seven patients were in in stage II-b and 7 in stage III. All patients underwent radiotherapy with no complication associated with chemotherapy (10 pts with CDDP, 2 pts with FOLFOX and 2 pts with FUFA). The downstaging after neadjuvant therapy was observed in 7/14 patients, and significant reduction of tumor diameter in 13/14 patients. There were 13 anterior resections and 1 abdominoperineal resections. EUS post-NCRT T stage was correct in 11/14 pts (3 T0, 5 T3, 3 T2), while 3 pts were over staged (2 T2 and 1 T1). Overall accuracy of EUS post-RCT for pathologic T stage was 93% for T0-T1 stage and 86% for T3 stage. EUS accuracy for N-stage was 79%. CONCLUSION: in our preliminary study neoadjuvant CRT was useful to downstage and downsize locally advanced RC. EUS seems to be an accurate tool to restage RC after neoadjuvant CRT. However our results needed to be confirmed in a large cohort of patients with locally advanced RC.

Background: Patients with FAP are not only at risk for colorectal cancer but also have an increased risk for duodenal and periampullary cancer. For this reason screening and surveillance of the upper gastrointestinal tract is recommended for these patients. The estimated lifetime risk of FAP patients to develop duodenal cancer is approximately 4 8%. The goal of screening is to identify those patients at the highest risk for developing duodenal or periampullary cancer. For this purpose the Spigelman classification was developed, enabling stratification of patients on both endoscopic and histological criteria. The endoscopic criteria are based on number (0, 1 4, 5 20, more than 20) and size of adenomas (0, 1 4 mm, 5 10 mm, larger than 10 mm). It is estimated that patients in the highest stage (stage IV) have a 36% chance of developing duodenal cancer within 10 years. In the management of FAP patients therefore the Spigelman stage plays a pivotal role. However, the interobserver agreement of the endoscopic part of the Spigelman classification is not known. Aim: To assess the interobserver variation for the endoscopic Spigelman classification in FAP patients. Methods: Four experienced endoscopists (2 more than 20 years experience; 2 approximately 5 years experience) with special interest in FAP from 3 academic centers patients reviewed high quality videos of upper GI endoscopies of 16 FAP patients. In each patient end-viewing and side-viewing instruments were used. Patients were randomly selected from surveillance programs. The observers were blinded for each other's results. Items scored were number and size of polyps in the antrum, duodenal segments and aspect of the papilla. Results: Interobserver agreement between the endoscopists was moderate at best with a kappa value of 0.44. Kappa values of les than 0.40 are considered to be poor or fair whereas a kappa value of more than 0.80 is considered good. There was no difference in kappa values between early or advanced stage FAP patients. Individual kappa values ranged between 0.33 and 0.74. Remarkably, the only good kappa score of 0.74 was between the two relatively inexperienced endoscopists. Conclusions: Although the management with regards to surveillance interval and interventions in FAP patients is guided by the Spigelman classification, this study clearly shows that interobserver agreement between endoscopists is moderate at best, even when evaluated by endoscopists with special interest and experience in FAP patients. This calls for caution when making decisions based on the Spigelman classification. It may also require further adaptation and simplification of the current classification.

Objective To compare the effectiveness of discontinuing treatment with amoxicillin after three days or eight days in adults admitted to hospital with mild to moderate-severe community acquired pneumonia who substantially improved after an initial three days9 treatment. Design Randomised, double blind, placebo controlled non-inferiority trial. Setting Nine secondary and tertiary care hospitals in the Netherlands. Participants Adults with mild to moderate-severe community acquired pneumonia (pneumonia severity index score ≤ 110). Interventions Patients who had substantially improved after three days9 treatment with intravenous amoxicillin were randomly assigned to oral amoxicillin (n = 63) or placebo (n = 56) three times daily for five days. Main outcome measures The primary outcome measure was the clinical success rate at day 10. Secondary outcome measures were the clinical success rate at day 28, symptom resolution, radiological success rates at days 10 and 28, and adverse events. Results Baseline characteristics were comparable, with the exception of symptom severity, which was worse in the three day treatment group. In the three day and eight day treatment groups the clinical success rate at day 10 was 93% for both (difference 0.1%, 95% confidence interval − 9% to 10%) and at day 28 was 90% compared with 88% (difference 2.0%, − 9% to 15%). Both groups had similar resolution of symptoms. Radiological success rates were 86% compared with 83% at day 10 (difference 3%, − 10% to 16%) and 86% compared with 79% at day 28 (difference 6%, − 7% to 20%). Six patients (11%) in the placebo group and 13 patients (21%) in the active treatment group reported adverse events (P = 0.1). Conclusions Discontinuing amoxicillin treatment after three days is not inferior to discontinuing it after eight days in adults admitted to hospital with mild to moderate-severe community acquired pneumonia who substantially improved after an initial three days9 treatment.

Endoscopic Pancreatic Duct Decompression in Treating Pancreatic Leakage: A Successful and Safe Method Jan-Werner Poley, Joos Heisterkamp, Jan Dees, Jelle Haringsma, Casper H.J. Van Eijck, Ernst J. Kuipers Introduction: Pancreatic leakage can occur as a consequence of abdominal trauma, acute pancreatitis or pancreatic surgery, especially distal pancreatectomy. In any case, it is a devastating complication associated with considerable morbidity and even mortality. Little is known about the best strategy in these patients, external drainage is most often performed and results in pancreatic fistulas with increased morbidity. Small series suggest that in selected cases decompression of the pancreatic ductal system through transpapillary stentplacement or sphincterotomy can achieve resolution of leakage. We therefore studied the effect of treatment of patients with persistent pancreatic leakage after surgery, trauma or pancreatitis with ERCP to achieve pancreatic ductal decompression and tried to identify determinants of outcome. Methods: Patients were identified from a database containing all endoscopic procedures in our institution between 2003 and 2005. Indications for ERCP were persistent symptomatic peripancreatic effusions with increased amylase activity. Follow-up ranged from 3 months to 2 years. The charts of all patients were reviewed. Results: ERCP was attempted in 25 patients (14 male; median age 51 yrs, range 8-73). Pancreatic injury was related to surgery (n Z 10), trauma (n Z 5) or pancreatitis (n Z 10). Pancreatic duct decompression with either stentplacement (n Z 19), or PD sphincterotomy (n Z 3) was technical successful in 22 patients (88%). Reasons for technical failure were BII anatomy, duodenal oedema and unsuccessful selective canulation. Successful long term outcome, defined as recovery without additional surgical or radiological procedures, was achieved in 76% (n Z 19) and failed in 24% (n Z 6). Three of six patients were in the pancreatitis group and three in the postoperative group (p Z 0.16 vs. trauma). In 10 patients repeat procedures were necessary due to stent dysfunction. Long term outcome was significantly different in patients with leakage in either head or body area (6/11 successful; 55%) versus patients with leakage in the tail area (13/13 successful; p Z 0.006). Three (12%) patients died; one in the postoperative group and two in the pancreatitis group. Stentplacement was successful in these patients and their deaths were unrelated to the procedure. In linear regression analysis only location of the leak was predictive of outcome (p Z 0.034), and not age, sex, indication, PD sphincterotomy or bridging of the leak with stentplacement. Conclusion: Endoscopic pancreatic ductal decompression is a highly effective method to treat pancreatic leakage in postoperative, trauma and pancreatitis patients, especially when the leak is located in the tail area.

Endoscopic Ablation of Intraepithelial Neoplasia in Barrett’s Patients Jelle Haringsma, Ilona Kerkhof, Jan Werner-Poley, Peter Siersema, Huug Tilanus, Ernst Kuipers Background: There is no generally accepted strategy for patients with intraepithelial neoplasia (IEN) in Barrett’s esophagus (BE). Esophagectomy is considered standard therapy for advanced cancer, and in many centers also for IEN. Surgical resection, however, carries considerable mortality and morbidity. Endoscopic ablation is developed as a minimally invasive organ-preserving therapy for IEN. There are limited data on outcome of such a strategy. We therefore aimed to determine the results of endoscopic ablation in patients referred for superficial neoplasia in BE. Methods: Prospective cohort study of all subjects with IEN referred to our tertiary center. 35 patients underwent endoscopic Mucosal Resection (EMR) of suspected BE lesions with a capped technique. In patients with high-grade neoplasia (Vienna class 4) endoscopic ablation was subsequently completed with Photodynamic Therapy (PDT) using 5-aminolevulinic acid 40 mg/kg at 633 nm 100J/ cm. Endoscopic biopsies were taken at 6 weeks, 3 mo and subsequently every 6 mo after PDT. Results: 56 patients (mean age 66 yrs, range 42-85) referred for superficial neoplasia in BE were evaluated. 7 patients with only low-grade IEN were followed. Primary surgical resection was performed in 10 of 49 patients based on endoscopic criteria, histological differentiation, and patient’s preference. 39 patients (80%) consented and were considered suitable for endoscopic ablation. Due to submucosal infiltration, poor differentiation and angio-invasion in the EMR specimen at histology, 5 were treated surgically, 4 were followed and 4 were treated otherwise. Endoscopic ablation was completed in 26. Of the latter group 21 patients had a sustained remission of severe neoplasia, 3 were subsequently treated surgically, 2 were followed. After a mean follow-up of 22 months, a total of 18/56 patients (32%) were operated upon. In 3 patients who had undergone EMR, no invasive cancer was found in the resection specimen. Operative mortality was 1/18 (5,5%). Three other patients died post-surgically: 1 from tumor recurrence, 2 from unrelated causes. Of 26 patients treated endoscopically, remission was sustained in 21 patients (81%). No major complications occurred. Conclusions: Endoscopic ablation can replace primary surgery in well-selected patients with severe intraepithelial neoplasia. Endoscopic ablation using EMR and PDT is safe and effective. Selection and endoscopic treatment of neoplasia in Barrett’s should be performed in expert centers. 495 A Randomized, Prospective Trial of Electrosurgical Incision Followed by Rabeprazole Versus Bougie Dilation Followed by Rabeprazole of Symptomatic Esophageal (Schatzki’s) Rings Jason C. Wills, Kristen Hilden, James DiSario, John C. Fang Background: Lower esophageal (Schatzki’s) rings are a common cause of solid food dysphagia. Standard treatment involves passage of a single large bougie to disrupt the ring but symptoms recur in the majority of patients. Electrosurgical incision of the ring may provide a longer duration of symptom improvement as suggested in a retrospective trial. Acid suppression has been shown to decrease the recurrence rate of peptic strictures but there is no data on the treatment of Schatzki’s rings. Aim: To compare the efficacy of bougie dilation to electrosurgical incision of symptomatic Schatzki’s rings at one year follow up in the presence of rabeprazole treatment. Methods: Forty-nine consecutive patients referred for endoscopic evaluation of dysphagia were randomized prior to EGD to Bougie dilation using a 52-54 French Maloney dilator or electrosurgical incision using a standard needle knife papillotome with 3-4 longitudinal incisions placed radially around the Schatzki’s ring. All patients completed validated GERD and dysphagia questionnaires at 0, 1, 3, 6, 9, and 12 months. All patients were placed on rabeprazole (20 mg/day) for the duration of the study. Analysis was made using Wilcoxon rank-sum (Mann-Whitney U) non-parametric test for independent samples (dysphagia score) and independent samples t-test (GERD scores and pH results). Results: Twenty-five patients underwent bougie dilation and 24 underwent electrosurgical incision. All patients had been followed for at least six months and an interim analysis was performed. There was one episode of bleeding in the incision group controlled with epinephrine injection. Dysphagia scores at 12 months decreased significantly in the incision group (median 5 / 0) compared with bougie group (median 7 / 3) (p Z 0.269). Both groups had significant improvement in GERD scores at 9 and 12 (p! 0.05). There was no difference in GERD improvement between the two groups at 12 (p Z 0.927). Conclusion: Electrosurgical incision of lower esophageal (Schatzki’s) rings is safe and offers similar improvement in dysphagia scores. Electrosurgical incision may offer more definitive relief of dysphagia (5/0) than bougie dilation (7/3) and require less frequent future interventions. Further follow up is needed. The addition of rabeprazole offered significant improvement in GERD scores in both groups.

In the last decade, computed tomographic (CT) and magnetic resonance (MR) colonography, two new cross-sectional techniques for imaging of the colon, emerged. Both techniques show promising initial results in the detection of polyps equal to or greater than 1 cm in diameter in symptomatic patients. Imaging protocols are still mostly under development and prone to change. Both CT and MR colonography generate a large number of source images, which have to be read carefully for filling defects and, if intravenous contrast material is used, enhancing lesions. An important postprocessing technique is multiplanar reformatting, which allows the viewer to see potential lesions in an orientation other than that of the source images. Virtual endoscopy, a volume rendering technique that generates images from within the colon lumen, is used for problem solving. CT and MR colonography have potential advantages over colonoscopy and double-contrast barium enema examination: multiplanar capabilities, detection of enhancing lesions that make the distinction between fecal residue and true lesion possible, and ante- and retrograde virtual colonoscopy. Currently, a number of studies suggest that patients have a preference for CT colonography over colonoscopy. Patients consider bowel cleansing the most uncomfortable part of any colon examination; hence, from the acceptance point of view, fecal tagging techniques are promising. Before CT and MR colonography can be implemented in daily practice, they must show approximately the same accuracy as colonoscopy for polyp detection in both symptomatic and screening patients.

Definitions of secondary endpoints. Table S1. Severity of PEP according to Cotton and revised Atlanta criteria. Table S2. Local and systemic complications according to (revised) Atlanta criteria. Table S3. ERCP-related complications (adopted from Cotton). SPIRIT checklist. (DOCX 40 kb)