- Email: [email protected]
1152 Treatment of Ulcer in Roux-En-Y Gastric Bypass
Abstracts
tertiary academic centers. Primary outcomes were overall and cancer free survival. Multivariable Cox proportional models were constructed to assess independent associations of potential prognostic variables with survival. Results: 199 patients were included of whom 121 (61%) underwent esophagectomy, with (69 [57%]) or without (52 [43%] preceding endoscopic resection). Baseline characteristics of the three groups are listed in Table 1. Patients who underwent surgery were younger (p < 0.0001), more likely to be male (pZ0.0120) and had a lower prevalence of lymphovascular invasion (LVI). Median follow up in patients who underwent esophagectomy and endoscopic therapy alone was 50.7 (IQR: 16.1-79.3) months and 32.2 (IQR: 7.8-60.9) months respectively. Overall survival at five year in the two groups was 75.0% and 53.8% respectively. Cancer free survival at five year in the two groups was 83.3% and 61.5% respectively. 4.1% of patient that underwent esophagectomy expired from operative complications. 43 (55%) subjects in the endoscopically treated group were cancer free at last follow up. 21 (24%) received adjuvant chemoradiation, while 33 (37.5%) received additional ablative therapy. On multivariable analysis (Table 2), esophagectomy was not associated with overall survival (hazard ratio [HR] Z 0.67, 95% CI: 0.36-1.27), while increasing age (HR per 10 years Z 1.42, CI: 1.05-1.94) and the presence of LVI (HR Z 3.05, CI: 1.27-7.58) were associated with decreased survival. Conclusions: In this large nonrandomized multicenter study of T1b EAC, surgery had higher overall and cancer free survival on univariable analysis, but when adjusted for relevant prognostic predictors; age, LVI, deep margin positivity; esophagectomy was not associated with reduced mortality. While decision-making should be individualized, based on patient and lesion characteristics, operative resection does not appear to offer a survival advantage over endoscopic therapy alone. Adjuvant chemo and/or radiotherapy following endoscopic resection merits further study.
Table 1
Age (mean [IQR]) Gender (Male %) LVI (n) Differentiation: Well to Moderate Differentiation: Poor to Undifferentiated Deep margin positivity (n) Node +ve resection (%) Adjuvant chemoradiation (%) BE segment length (median [IQR]) No BE* NDBE* LGD/IND* HGD* EAC* Death from all causes (n) Death from EAC (n)
Treated endoscopically (nZ88) 73.3 (65.8-18.0) 76.9 20 50
Esophagectomy preceded by EMR (nZ69)
Esophagectomy without EMR (nZ 52)
p-value
65.5 (59.8-71.1) 94.2 20 39
67.4 (61.4-74.9) 86.5 6 16
<0.0001 0.0120
27
27
34
42
41 (in EMR)
26.9
17.4 5.8
4.9 (2-7)
4.1 (0-6.5)
23 10 10 10 25
(29.5) (12.8) (12.8) (12.8) (23.1) 23 4
23.1 22.0
9 3
0.44 0.0031
18 4
*At last histological evaluation. BE Z Barrett’s esophagus, EAC Z esophageal adenocarcinoma, HGD Z high-grade dysplasia, IQR Z interquartile range, LGD Z low-grade dysplasia, IND Z Indefinite for dysplasia, LVI Z lymphovascular invasion, NDBE Z non-dysplastic Barrett’s esophagus
Table 2 Predictors of overall mortality Univariable analysis
Multivariable analysis
Parameter (reference)
HR
95% CI
pvalue
Age [+10 years] Gender (male) Esophagectomy (yes) LVI (absent) Present Other
1.47 1.08 0.53
1.10, 1.97 0.44, 2.28 0.30, 0.95
0.009 0.85 0.03
1.42 1.05, 1.94
0.02
0.67 0.36, 1.27
0.21
2.49 1.66
1.05, 6.13 0.81, 3.76
0.11
3.05 1.27, 7.58 1.93 0.933, 4.38
0.04
Poor/undifferentiated (yes) Deep margin positivity (absent)
1.18 1.40
0.66, 2.12 0.79, 2.47
0.59 0.24
1.21 0.67, 2.17
0.52
www.giejournal.org
HR
95% CI
pvalue
1152 Treatment of Ulcer in Roux-En-Y Gastric Bypass Allison Schulman*, Christopher C. Thompson Brigham & Women’s Hospital, Boston, MA Background: Ulceration at the site of the gastrojejunal anastomosis (GJA) is a common complication of Roux-en-Y gastric bypass (RYGB), and may lead to chronic stenosis of the stoma. Despite maximum medical management, a percentage of ulcers persist, and aggressive endoscopic balloon dilation for symptom management is often deferred given high risk of perforation with an ulcer present. We demonstrate the placement of a lumen-apposing metal stent (LAMS) to promote healing of ulceration at the gastrojejunal anastomosis. Case illustration: A 47 year-old woman underwent RYGB two years prior. Her course was complicated by persistent ulceration on the jejunal aspect of the GJA leading to chronic stenosis. Despite maximum medical therapy and gentle endoscopic balloon dilation, the ulcer and stenosis persisted. We demonstrate placement of a LAMS across the GJA, with subsequent dilation through the lumen of the stent. Upon removal of the stent six weeks later, the ulceration has healed and the stenosis improved. The patient is then able to undergo aggressive endoscopic balloon dilation for stenosis management. The patient’s symptoms ultimately resolved with this therapy. Endoscopic methods: A wire is initially passed through the GJA. The stent delivery system is then positioned over the wire. Because this procedure does not require endoscopic ultrasound, a wide channel upper endoscope is used for stent deployment. Care is taken to ensure that the distal flange is deployed distal to the GJA stricture on the jejunal aspect of the anastomosis. The stent was then slowly released through the catheter until the proximal flange was appropriately positioned within the gastric pouch, fully containing the ulcer beneath. A hydrostatic balloon was then used to dilate the intraluminal portion of the stent up to 13.5 mm. The balloon is held in position for one minute. Six weeks later, biopsy forceps are used to grasp onto the stent wall, and ultimately used to remove the stent. Following removal, the GJA is less stenotic, and no ulceration is apparent. Clinical implications: Placement of a LAMS across the GJA promotes ulcer healing and offers a novel approach for management of anastomotic stenosis.
1153 Outcomes of Esophageal Self-Dilation for Patients With Refractory Benign Esophageal Strictures Yi Qin*, Dharma B. Sunjaya, Sarel J. Myburgh, Jeffrey A. Alexander, Magnus Halland Gastroenterology, Mayo Clinic, Rochester, MN Background and objectives: Current management of refractory benign esophageal strictures (RBES), which consists of repeated endoscopic dilations and in some cases stent placement, leads to resolution of dysphagia in only 30% of patients1. Esophageal self-dilation, where patients are taught to independently pass a polyvinyl dilator to maintain esophageal patency may be an alternative, a prior study suggested efficacy and safety2. We therefore aimed to evaluate the efficacy and safety of esophageal self-dilation at a tertiary esophageal referral center. Methods: We conducted a retrospective review of all patients with RBES who participated in esophageal self-dilation for RBES at Mayo Clinic (Rochester, MN) between January 2003 and September 2016. Only patients who had consented for use of medical records for research were included. Clinical data regarding stricture characteristics, change in dysphagia, number of endoscopic therapies before and after starting self-dilation, and complications were collected. RBES was defined as persistent or recurrent dysphagia after at least 5 prior endoscopic interventions. Dysphagia was quantified using the Dakkak and Bennett score3 (0 Z no dysphagia, 1 Z dysphagia to solids, 2Z dysphagia to semi-solids, 3Z dysphagia to liquids, 4Z aphagia). Results: We identified 40 patients who participated in esophageal self-dilation. Basic demographic and clinical features are presented in Table 1. There was a significant reduction in the mean number of endoscopic dilations, which was 13.9 (range 5-51) before starting self-dilation, versus 1.2 after self-dilation (range 0-9), p <0.0001. Mean dysphagia score on presentation was 2.7 (range 0-4) versus 0.5 (range 0-2) after selfdilation, p <0.0001. 19 patients received enteral nutrition prior to commencement of self-dilation, whereas only 6 patients required enteral feeding after starting selfdilation. Of the 40 patients, 6 had moderate adverse events (3 bleeding requiring transfusion or endoscopy, 3 perforations requiring hospitalization but not surgery), 3 had mild adverse events (1 esophagitis, 1 pain, and 1 ulceration). There was no fatality as result of the self-dilation. Conclusions: Esophageal self-dilation, when used after establishing a desired esophageal diameter with serial endoscopic dilations, is an effective and safe way of maintaining esophageal patency in RBES. It can significantly reduce the number of endoscopic procedures, and appears to be a superior therapeutic strategy compared to standard clinical care. 1. Repici, Kochman. Gastrointest Endosc. 2016 84(2):222-8 2. Dzeletovic, Alexander. Dig Dis Sci. 2013 58(11):3218-23 3. Dakkak, Bennett. J Clin Gastroenterol. 1992 14:99-100
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB155
tertiary academic centers. Primary outcomes were overall and cancer free survival. Multivariable Cox proportional models were constructed to assess independent associations of potential prognostic variables with survival. Results: 199 patients were included of whom 121 (61%) underwent esophagectomy, with (69 [57%]) or without (52 [43%] preceding endoscopic resection). Baseline characteristics of the three groups are listed in Table 1. Patients who underwent surgery were younger (p < 0.0001), more likely to be male (pZ0.0120) and had a lower prevalence of lymphovascular invasion (LVI). Median follow up in patients who underwent esophagectomy and endoscopic therapy alone was 50.7 (IQR: 16.1-79.3) months and 32.2 (IQR: 7.8-60.9) months respectively. Overall survival at five year in the two groups was 75.0% and 53.8% respectively. Cancer free survival at five year in the two groups was 83.3% and 61.5% respectively. 4.1% of patient that underwent esophagectomy expired from operative complications. 43 (55%) subjects in the endoscopically treated group were cancer free at last follow up. 21 (24%) received adjuvant chemoradiation, while 33 (37.5%) received additional ablative therapy. On multivariable analysis (Table 2), esophagectomy was not associated with overall survival (hazard ratio [HR] Z 0.67, 95% CI: 0.36-1.27), while increasing age (HR per 10 years Z 1.42, CI: 1.05-1.94) and the presence of LVI (HR Z 3.05, CI: 1.27-7.58) were associated with decreased survival. Conclusions: In this large nonrandomized multicenter study of T1b EAC, surgery had higher overall and cancer free survival on univariable analysis, but when adjusted for relevant prognostic predictors; age, LVI, deep margin positivity; esophagectomy was not associated with reduced mortality. While decision-making should be individualized, based on patient and lesion characteristics, operative resection does not appear to offer a survival advantage over endoscopic therapy alone. Adjuvant chemo and/or radiotherapy following endoscopic resection merits further study.
Table 1
Age (mean [IQR]) Gender (Male %) LVI (n) Differentiation: Well to Moderate Differentiation: Poor to Undifferentiated Deep margin positivity (n) Node +ve resection (%) Adjuvant chemoradiation (%) BE segment length (median [IQR]) No BE* NDBE* LGD/IND* HGD* EAC* Death from all causes (n) Death from EAC (n)
Treated endoscopically (nZ88) 73.3 (65.8-18.0) 76.9 20 50
Esophagectomy preceded by EMR (nZ69)
Esophagectomy without EMR (nZ 52)
p-value
65.5 (59.8-71.1) 94.2 20 39
67.4 (61.4-74.9) 86.5 6 16
<0.0001 0.0120
27
27
34
42
41 (in EMR)
26.9
17.4 5.8
4.9 (2-7)
4.1 (0-6.5)
23 10 10 10 25
(29.5) (12.8) (12.8) (12.8) (23.1) 23 4
23.1 22.0
9 3
0.44 0.0031
18 4
*At last histological evaluation. BE Z Barrett’s esophagus, EAC Z esophageal adenocarcinoma, HGD Z high-grade dysplasia, IQR Z interquartile range, LGD Z low-grade dysplasia, IND Z Indefinite for dysplasia, LVI Z lymphovascular invasion, NDBE Z non-dysplastic Barrett’s esophagus
Table 2 Predictors of overall mortality Univariable analysis
Multivariable analysis
Parameter (reference)
HR
95% CI
pvalue
Age [+10 years] Gender (male) Esophagectomy (yes) LVI (absent) Present Other
1.47 1.08 0.53
1.10, 1.97 0.44, 2.28 0.30, 0.95
0.009 0.85 0.03
1.42 1.05, 1.94
0.02
0.67 0.36, 1.27
0.21
2.49 1.66
1.05, 6.13 0.81, 3.76
0.11
3.05 1.27, 7.58 1.93 0.933, 4.38
0.04
Poor/undifferentiated (yes) Deep margin positivity (absent)
1.18 1.40
0.66, 2.12 0.79, 2.47
0.59 0.24
1.21 0.67, 2.17
0.52
www.giejournal.org
HR
95% CI
pvalue
1152 Treatment of Ulcer in Roux-En-Y Gastric Bypass Allison Schulman*, Christopher C. Thompson Brigham & Women’s Hospital, Boston, MA Background: Ulceration at the site of the gastrojejunal anastomosis (GJA) is a common complication of Roux-en-Y gastric bypass (RYGB), and may lead to chronic stenosis of the stoma. Despite maximum medical management, a percentage of ulcers persist, and aggressive endoscopic balloon dilation for symptom management is often deferred given high risk of perforation with an ulcer present. We demonstrate the placement of a lumen-apposing metal stent (LAMS) to promote healing of ulceration at the gastrojejunal anastomosis. Case illustration: A 47 year-old woman underwent RYGB two years prior. Her course was complicated by persistent ulceration on the jejunal aspect of the GJA leading to chronic stenosis. Despite maximum medical therapy and gentle endoscopic balloon dilation, the ulcer and stenosis persisted. We demonstrate placement of a LAMS across the GJA, with subsequent dilation through the lumen of the stent. Upon removal of the stent six weeks later, the ulceration has healed and the stenosis improved. The patient is then able to undergo aggressive endoscopic balloon dilation for stenosis management. The patient’s symptoms ultimately resolved with this therapy. Endoscopic methods: A wire is initially passed through the GJA. The stent delivery system is then positioned over the wire. Because this procedure does not require endoscopic ultrasound, a wide channel upper endoscope is used for stent deployment. Care is taken to ensure that the distal flange is deployed distal to the GJA stricture on the jejunal aspect of the anastomosis. The stent was then slowly released through the catheter until the proximal flange was appropriately positioned within the gastric pouch, fully containing the ulcer beneath. A hydrostatic balloon was then used to dilate the intraluminal portion of the stent up to 13.5 mm. The balloon is held in position for one minute. Six weeks later, biopsy forceps are used to grasp onto the stent wall, and ultimately used to remove the stent. Following removal, the GJA is less stenotic, and no ulceration is apparent. Clinical implications: Placement of a LAMS across the GJA promotes ulcer healing and offers a novel approach for management of anastomotic stenosis.
1153 Outcomes of Esophageal Self-Dilation for Patients With Refractory Benign Esophageal Strictures Yi Qin*, Dharma B. Sunjaya, Sarel J. Myburgh, Jeffrey A. Alexander, Magnus Halland Gastroenterology, Mayo Clinic, Rochester, MN Background and objectives: Current management of refractory benign esophageal strictures (RBES), which consists of repeated endoscopic dilations and in some cases stent placement, leads to resolution of dysphagia in only 30% of patients1. Esophageal self-dilation, where patients are taught to independently pass a polyvinyl dilator to maintain esophageal patency may be an alternative, a prior study suggested efficacy and safety2. We therefore aimed to evaluate the efficacy and safety of esophageal self-dilation at a tertiary esophageal referral center. Methods: We conducted a retrospective review of all patients with RBES who participated in esophageal self-dilation for RBES at Mayo Clinic (Rochester, MN) between January 2003 and September 2016. Only patients who had consented for use of medical records for research were included. Clinical data regarding stricture characteristics, change in dysphagia, number of endoscopic therapies before and after starting self-dilation, and complications were collected. RBES was defined as persistent or recurrent dysphagia after at least 5 prior endoscopic interventions. Dysphagia was quantified using the Dakkak and Bennett score3 (0 Z no dysphagia, 1 Z dysphagia to solids, 2Z dysphagia to semi-solids, 3Z dysphagia to liquids, 4Z aphagia). Results: We identified 40 patients who participated in esophageal self-dilation. Basic demographic and clinical features are presented in Table 1. There was a significant reduction in the mean number of endoscopic dilations, which was 13.9 (range 5-51) before starting self-dilation, versus 1.2 after self-dilation (range 0-9), p <0.0001. Mean dysphagia score on presentation was 2.7 (range 0-4) versus 0.5 (range 0-2) after selfdilation, p <0.0001. 19 patients received enteral nutrition prior to commencement of self-dilation, whereas only 6 patients required enteral feeding after starting selfdilation. Of the 40 patients, 6 had moderate adverse events (3 bleeding requiring transfusion or endoscopy, 3 perforations requiring hospitalization but not surgery), 3 had mild adverse events (1 esophagitis, 1 pain, and 1 ulceration). There was no fatality as result of the self-dilation. Conclusions: Esophageal self-dilation, when used after establishing a desired esophageal diameter with serial endoscopic dilations, is an effective and safe way of maintaining esophageal patency in RBES. It can significantly reduce the number of endoscopic procedures, and appears to be a superior therapeutic strategy compared to standard clinical care. 1. Repici, Kochman. Gastrointest Endosc. 2016 84(2):222-8 2. Dzeletovic, Alexander. Dig Dis Sci. 2013 58(11):3218-23 3. Dakkak, Bennett. J Clin Gastroenterol. 1992 14:99-100
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB155