Patent foramen ovale has been identified as a conduit for paradoxical embolism resulting in cryptogenic stroke or transient ischemic attack (TIA). We aimed to establish rates of death, recurrent stroke or TIA among patients undergoing PFO closure for stroke or TIA at our unit. A retrospective analysis of all PFO closure patients was performed between May 2004 and January 2013. Follow up was performed by mortality tracing using the Medical Research Information Service of the Office of National Statistics. With regard to stroke or TIA recurrence, written consent forms and questionnaires were mailed with follow up telephone calls. Medical notes and imaging records were consulted where adverse events were noted. 301 patients aged 48.6 6 11.0 years, 54.4% male, with !1 thromboembolic neurovascular event had percutaneous PFO closure with one of eight devices, with successful implantation in 99% of cases. Followup duration was 40.2 6 26.2 months (range 1.3-105.3); complete in 301 patients for mortality (100%) and 283 patients (94.0%) for neurovascular events. Two patients died during follow-up (respiratory failure n 5 1; road traffic accident n 5 1). Recurrent stroke (MRI or CT confirmed) was observed in five patients (0.5%; 0.55 per 100 person-years) and TIA in 9 (1.1%; 0.98 per 100 person-years). Atrial fibrillation requiring treatment was documented in 14 patients (1.7%). Percutaneous PFO closure in patients with cryptogenic stroke or TIA is a safe treatment with a low incidence of procedural complications and recurrent neurovascular events. Registry data like these may help to demonstrate the utility of PFO closure in stroke. V C 2015 Wiley Periodicals, Inc.

ObjectiveEndoscopic ultrasound-guided through-the-needle microbiopsy (EUS-TTNB) forceps is a recent development that facilitates sampling of the walls of pancreatic cystic lesions (PCL) for histological analysis. We aimed to assess the impact of EUS-TTNB and its influence on patient management in a tertiary pancreas centre.DesignA prospective database of consecutive patients who underwent EUS-TTNB from March 2020 to August 2022 at a tertiary referral centre was retrospectively analysed.ResultsThirty-four patients (22 women) were identified. Technical success was achieved in all cases. Adequate specimens for histological diagnosis were obtained in 25 (74%) cases. Overall, EUS-TTNB led to a change in management in 24 (71%) cases. Sixteen (47%) patients were downstaged, with 5 (15%) discharged from surveillance. Eight (24%) were upstaged, with 5 (15%) referred for surgical resection. In the 10 (29%) cases without change in management, 7 (21%) had confirmation of diagnosis with no change in surveillance, and 3 (9%) had insufficient biopsies on EUS-TTNB. Two (6%) patients developed post-procedural pancreatitis, and 1 (3%) developed peri-procedural intracystic bleeding with no subsequent clinical sequelae.ConclusionEUS-TTNB permits histological confirmation of the nature of PCL, which can alter management outcomes. Care should be taken in patient selection and appropriately consented due to the adverse event rate.

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Upper gastrointestinal bleeding is a common medical emergency with associated significant morbidity and mortality. There are multiple published national and international guidelines on the management of acute upper gastrointestinal bleeding (AUGIB). However, the 2015 National Confidential Enquiry into Patient Outcome and Death group (NCEPOD) report identified several areas of concern regarding suboptimal care. This article discusses the latest evidence and guidance on the pre-endoscopic, endoscopic and post-endoscopic management of patients presenting with AUGIB. AUGIB should be assessed for risk stratification using a validated score, such as the Glasgow-Blatchford Score, Rockall Score or AIMS65. Treatment considerations include the optimum threshold for red blood cell transfusion, as well as the reintroduction of antithrombotic agents. Novel endoscopic therapies include haemostatic powder spray, over-the-scope clips, ultrasound doppler probes and self-expandable oesophageal stents.

IntroductionUpper gastroenterology tract cancers (UGIT) are the 4 th commonest malignancy worldwide. The best treatment remains early detection allowing for prompt intervention. Oesophagogastroduodenoscopy (OGD) is the gold standard of diagnosing UGIT cancers however it remains imperfect. There is still a substantial rate of missed UGIT cancers at endoscopy. It is estimated that in the UK the national rate of missed UGIT cancers is 7.2%.It is important that endoscopic techniques undergo regular review ensuring a process of continuous quality improvement. Our aim is to review the missed rate of cancers after a negative OGD examination and to explore the reasons behind this and to propose methods of reducing the rate of missed cancers.MethodsA retrospective case analysis over a five year period (2010–2015) investigating patients who received a diagnosis of UGIT cancer at our local district general hospital. We used our local clinical databases in identifying relevant patients who had been investigated with a negative endoscopy in the prior year but then went on to receive a diagnosis of colorectal cancer.Results415 patients (F 143; M 272) were audited with an average age of 76 (range 31–102). 31 patients were excluded as cancer diagnosis was discovered by other means (CT, ERCP and emergency operations). Of the 415 patients audited 54 (14%) were investigated with an OGD in the prior year which was negative. We also investigated the presenting pathway and found that the majority of patients (166; 28%) were presenting through the urgent suspected cancer pathway.ConclusionOur results show a high rate of missed lesions on initial endoscopy. This has serious implications for practice and suggested published reasons for this are largely thought to be the variability in experience of the endoscopist. To that end it is our recommendation that training for OGD be prolonged. There is also a large variability in reporting of the procedure therefore following a more standardised approach is advocated. Also operators are strongly encouraged to take multiple biopsies of lesions that appear suspicious. Finally we would like to implement a strict, rigorous follow up system whereby patients presenting with alarm symptoms and a negative OGD can be followed up with repeat procedures to ensure no cancers are missed.References1 Yalamarthi S, Witherspoon P, McCole D, Auld CD. Missed diagnosis with upper gastrointestinal cancers. Endoscopy 2004;36(10):874–9.2 Gado A, Ebeid B. Gastric cancer missed at endoscopy. Alexandria Journal of Medicine 2013;49(1):25–27.3 Enns R. Missed cancers in the upper gastrointestinal tract after esophagogastroduodenoscopy. Gastroenterol Hepatol 2010;6:691–693.Disclosure of InterestNone Declared

IntroductionColonoscopy is the “gold standard” approach to investigating symptoms in relation to the colon. However, recent literature has shown that colonoscopy as a diagnostic test for colorectal cancer is far from perfect with a cancer missed rate of 8.6% in the UK. We aim to identify the rate of colorectal cancers diagnosed following a negative flexible sigmoidoscopy and/or colonoscopy and to explore contributing factors.MethodsThis is a retrospective case analysis investigating all patients who received a diagnosis of colorectal cancer over a five-year period (2010–2015). We used our local clinical databases in identifying those patients who had negative flexible sigmoidoscopy and/ or colonoscopies but subsequently received a diagnosis of colorectal cancer.Results368 (Females 156; males 167; average age 76.71) patients were included in the initial sample. Of those 45 were excluded as an initial endoscope examination was not carried out and the cancers were identified by other means. Of 368 patients who were diagnosed with colorectal cancer, 35 (10.83%) had a previously normal endoscopic examination (19 flexible sigmoidoscopy; 16 colonoscopy)ConclusionThis research has shown that despite being the gold standard, colonoscopy as a diagnostic test for colorectal cancer is still far from perfect. In keeping with current research there appears to be a missed rate in detection of colorectal cancers, polyps and adenomas. Factors contributing to missed lesions are thought to be the presence of >2 lesions, lesions present in the left side of the colon, withdrawal time where longer withdrawal time was associated with higher lesion detection rate. Furthermore the smaller the lesion the lower the detection rate on colonoscopy (missed rate: 6% in adenomas >1 cm; 27% in adenomas <5 mm). It is worth bearing in mind that endoscopic procedures are very dependant on operator experience. We recommend longer and more rigorous training in endoscopic procedures and strongly advise following the standardised reporting systems in place.References1 Rex DK, Cutler CS, Lemmel GT, Rahmani EY, Clark DW, Helper DJ, Lehman GA, Mark DG. Colonoscopic miss rates of adenomas determined by back-to-back colonoscopies. Gastroenterology 1997;112(1):24–8.2 Barclay RL, Vicari JJ, Doughty AS, Johanson JF, Greenlaw RL. Colonoscopic withdrawal times and adenoma detection during screening colonoscopy. New England Journal of Medicine 2006;355:2533–2541.Disclosure of InterestNone Declared