Introduction: Cold snare endoscopic mucosal resection (CS-EMR) has become increasingly popular for the removal of colon polyps . 10 mm. CS-EMR can potentially avert some of the risks associated with the use of electrocautery during polyp resection without compromising clinical efficacy. Therefore, we conducted a systematic review and meta-analysis to evaluate the efficacy and safety of CS-EMR in removing colon polyps. Methods: We conducted a comprehensive literature search of MEDLINE, EMBASE, Cochrane, ClinicalTrials.gov, and Scopus databases for studies published in the English language addressing outcomes of CS-EMR for colon polyps from database inceptions through April 2022. The weighted pooled estimates with the 95% confidence interval (CI) were calculated. Cochran Q test and I 2 statistics were used to evaluate heterogeneity. Results: We identified 3599 articles on the initial search, and 32 full-text studies were assessed for eligibility. Fifteen studies met inclusion criteria. There were three randomized controlled trials, six prospective, and six retrospective studies. Six studies were from the United States, two each from Australia, China, and Japan, one from the United Kingdom, and one from Greece. A total of 2382 polyps were removed from 1756 patients. 45% were females. Polyps ranged from 6-80 mm in size, and 72.4% were proximal to the splenic flexure. In addition, 50.4% of the polyps were NICE I or serrated lesions and 48.5% were NICE II, and 0.1% were NICE III. Polyp recurrence rate after CS-EMR was 9.4 % (95% CI: 3.3-15.6%, I 2 5 95.8%), piecemeal resection rate 59.4% (95% CI: 46.3-72.4%, I25 99.9%), and complete histological resection rate (defined by post polypectomy biopsies) was 93.1% (95% CI: 88.7-97.6%, I 2 590.8%). For adverse events, delayed post-polypectomy bleeding rate was 0.8% (95% CI: 0.3-1.3%, I 2 5 21.4%), perforation and the post-polypectomy syndrome rate was 0.3% (95% CI: 0-0.5%, I 2 5 0%) (Figure). Given significant heterogeneity in recurrence rate, subgroup analyses were performed. Recurrence rate in serrated lesions (n5484) was 3.8% (95% CI: 0.2-7.4%, I 2 5 76.7%), in polyps , 20 mm (n5 137) 0.8% (95% CI: -0.7-2.3%, I 2 5 0%), and in polyps $ 20 mm (n5617) 15.7% (95% CI: 2.6-28.7%, I 2 5 95.2%). Conclusion: CS-EMR has an excellent safety profile and acceptable recurrence rate for resection of colon polyps, especially for polyps , 20 mm and serrated lesions. However, large prospective studies to validate safety and efficacy are needed.[0161] Figure 1. Forest plots of A) recurrence rate, B) complete histological resection, C) delayed post polypectomy bleeding, and D) perforation of cold snare endoscopic mucosal resection in colon polyps

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Introduction: Inflammatory dysregulation of the coagulation cascade and vascular stasis in hospitalized necrotizing pancreatitis (NP) patients serve as a milieu for venous thromboembolism which is often underrecognized. We aimed to identify the incidence and independent risk factors for deep vein thrombosis (DVT) and pulmonary embolism (PE) in our NP cohort. Methods: All adult NP patients hospitalized at our center between 2009 and 2022 were identified from a prospective database and categorized into two groups based on development of DVT or PE (cases) or not (controls), within 6 months after NP hospitalization. Baseline data included demographics, ASA score, SIRS and organ failure on admission and at 48 hours, interventions (endoscopic, percutaneous or surgical), length of stay, transfer status, need for ICU, clinical and imaging characteristics and anticoagulation during admission. Univariable and multivariable analysis identified independent predictors for DVT and PE. P , 0.05 was considered significant. Results: Among 641 NP patients, 510 patients [males 349 (68%), median age 52 years (IQR 38-64)] were eligible for inclusion. DVT/PE developed in 62 (12%) patients; 26 DVT (5%), 22 PE (4%) and 14 with both (3%) after a median 17 (IQR 7-34) days from NP. Demographics were similar between groups though cases were older with more comorbidities (higher ASA) including a personal history of cancer. Nearly all patients [n 5 506, (99%)] including all cases were on DVT prophylaxis (pharmacologic or mechanical) during hospitalization. Significant clinical and imaging predictors for DVT/PE on multivariable analysis were age (.50 years) [OR 2.1 (1.05-4.13)], personal history of cancer ], peripancreatic extent )], infected necrosis ] and increased length of stay (LOS) ]. Conclusion: Incidence of DVT/PE in our NP cohort was 12% (comparable to incidence rates in cancer and IBD), usually diagnosed within one month of NP hospitalization. Age .50, peripancreatic necrosis extent, personal history of cancer, infected necrosis, and prolonged hospitalization were independent risk factors. This high-risk group of patients may benefit from intensified DVT prophylaxis during hospitalization and closer follow up after discharge (Table 1).

Introduction: Over-the-scope clips (OTSC) have been increasingly used in the management of bleeding, perforations, fistulae, and anastomotic leaks in the gastrointestinal tract. However, since their Food and Drug Administration (FDA) approval in 2010, data on the adverse events of OTSC systems has been lacking. Our study aims to report and analyze adverse events and device failures associated with OTSC systems using the FDA's Manufacturer and User Facility Device Experience (MAUDE) database. Methods: We analyzed the post-marketing surveillance data from the FDA MAUDE database of the two OTSC systems available in the United States: The Padlock clip system and the Ovesco OTSC from April 2017 through May 2022.Results: Thirty-six medical device reporting claims were found from May 2017 through May 2022. Adverse events were classified as device-related problems and patient-related adverse events. Thirty-six devicerelated problems were reported, along with sixteen device-related adverse events (Table ). Most device-related problems were reported in the Padlock defect closure system (n523), followed by the Padlock pro clip system (n58) and Ovesco OTSC clip system (n55). The most common device-related problem was related to the failure of deployment of OTSC (n514), followed by material protrusion or extrusion (n56). The most common patient adverse events were perforation (n54), bleeding (n53), esophageal laceration (n53) and luminal stenosis (n52). Three out of four perforations were in the Padlock pro select closure system. All four patients required surgical management of the perforation. No deaths related to the use of OTSC were reported. Conclusion: Using the data from a publicly available database, the overall adverse events from OTSC systems remain low. Failure of OTSC deployment and perforation were the most common device-related problem and patient-related adverse events, respectively. The identification of common adverse events has the potential to optimize device design and patient outcomes. It is important for endoscopists to be mindful of these potential adverse events when using over-the-scope clips.

Introduction: Endoscopic visualization of varices can be challenging in some clinical scenarios. Here we describe three cases in which endoscopic ultrasound (EUS) was used to identify and treat varices. Case Description/Methods: Case 1: a 62-year-old woman with decompensated cirrhosis and isolated gastric fundal varices treated with prior glue injection presented with her second episode of upper gastrointestinal (GI) bleeding. Urgent esophagogastroduodenoscopy (EGD) showed a glue cast ulcer without obvious gastric varices. EUS revealed tubal, anechoic structures in the fundus of the stomach consistent with varices. A 19-gauge access needle was used to puncture the varices with return of blood flow. Three 10mm embolization coils followed by 8 ml of gel foam-normal saline slurry were injected into the varix. Doppler post-treatment showed a decrease in the flow of the treated varix and of the deeper varices. Case 2: a 60-year-old man with non-cirrhotic portal hypertension from portal vein thrombosis was admitted for hemorrhagic shock from gastric variceal hemorrhage. Endoscopic evaluation showed non-bleeding gastroesophageal varices. Surveillance endoscopy one week later showed no obvious gastric varices, but EUS identified two large gastric fundus varices which were treated with two 8 mm coil and 8 ml gel foam. Complete thrombosis of both varices was noted. Surveillance EUS-guided treatment was performed until eradication without recurrence. Case 3: a 63-year-old man with decompensated cirrhosis presented with recurrent rectal variceal bleeding after previous treatment with glue injection. Flexible sigmoidoscopy showed few glue cast rectal ulcers with no obvious bleeding. EUS showed a varix of 5 x 15 mm which was treated with a 10 x 14 mm embolization coil and 4 ml of gel-foam normal saline slurry leading to eradication. Surveillance endoscopy in two weeks showed decompression of rectal varices. Discussion: In all three cases, EGD performed for recent gastrointestinal bleeding did not show any evidence of varices. However, EUS could precisely localize the feeder vessels, verify the needle placement into the vessel by aspirating blood and inject coils followed by gel foam into varices in a targeted manner. Successful treatment of varices was confirmed by the decrease in Doppler flow of the treated varices. No postprocedure adverse events such as pain, bleeding or embolization were noted. This illustrates the utility of EUS in the treatment of varices when they are not detected endoscopically. Watch the video at https:// tinyurl.com/ACGAbstractS360