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980 BRAVO Wireless Esophageal pH Monitoring: A More Cost-Effective Approach Than Empiric Proton-Pump Inhibitor Therapy for Suspected Gastroesophageal Reflux Disease
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comorbidity score, incidence of Type IV hernias (28% vs. 14%) and presentation of intrathoracic stomach >75% (60% vs. 43%) were all more common in the acute group. Operations were longer (174 vs. 154 min.) but blood loss was similar. In AR, mean length of hospital stay was higher (5.72 vs. 4.4 days), median (4 vs 4). There was no difference in perioperative complications on incidence of readmissions. One patient in the ER group died, overall mortality 0.2%. Conclusions: Acute presentation associated with PEH can be managed successfully with comparable outcomes to elective operations in high volume centers. Many patients can and should be treated with guided decompression for acute incarceration and obstruction. Patients with large PEH and recurrent chest pain should routinely be considered for elective repair.
Adjunctive Multiple Rapid Swallows Increases Sensitivity of High Resolution Manometry in Patients With Dysphagia Shunsuke Akimoto, Se Ryung Yamamoto, Harit Kapoor, Tommy H. Lee, sumeet K. mittal
SSAT Abstracts
Introduction Patients with dysphagia are assessed with normal High Resolution Manometry (HRM) , the current gold standard. Recently, provocative Multiple Rapid Swallow technique (MRS) has been reported to provide additional detail in characterization of the esophageal transit. The aim of this study is to compare the test-characteristics of HRM with adjunctive MRS in the detection of patients with dysphagia. Methods All patients undergoing HRM evaluation between June 2014 to October 2014 were additionaly administered the MRS. Patients swallowed four 2ml water boluses, each four seconds apart. The parameters measured were Post-Deglutitory Inhibition(PDI) and the success of Rebound Esophageal Contraction(REC) using the 30mmHg isobaric contour. PDI was considered complete unless a contraction measuring > 3cm was identified, wherein it was considered incomplete. REC was considered failed when there was no smooth muscle contraction, the intersegmental trough was >3cm or when the contraction was interrupted for >3cm. We compared the sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of HRM alone and with adjunctive MRS in the detection of dysphagia. Patients with known achalasia or previous foregut surgery were excluded. Results Sixty-five patients underwent HRM during the study period, of which 46 met the inclusion criteria. The mean age of the group was 57 years with 19 (41.3%) males. Twenty-nine (63%) patients had dysphagia. Those with and without dysphagia had similar mean age (57.2 vs. 56.7) and gender distribution (males%; 37.9% vs. 47.1%). On HRM, patients with and without dysphagia had similar Integrated relaxation pressures (IRP) (9.2 vs. 9.9; p=0.771) and Distal contractile integral (DCI) (2821 vs. 2552; p=0.671). In patients with dysphagia, REC failure (65.52%) was more common than abnormal PDI (37.9%) and outflow obstruction (IRP^15) (13.8%). Patients with dysphagia had significantly higher rate of REC failure when compared to patients without dysphagia (65.5% vs. 35.3%; p=0.047) but PDI was not statistically different (37.9% vs. 23.5%; p=0.315). The Se, PPV and NPV of REC component of the test was much higher than the PDI component (Se; 65.5% vs. 37.9%, PPV; 76% vs. 73.3%; NPV: 52.4% vs. 41.9%). The Sp of the PDI component was marginally higher than that of the REC (76.5% vs. 64.7%). Overall, MRS, especially the REC component stood out as a better indication of dysphagia than conventional HRM alone (Se; 41.4%, Sp; 64.7%, PPV; 66.7%, NPV; 39.3%). Conclusion MRS seems to be a valuable adjunct in the evaluation of dysphagia. It identified an additional 10 patients as having abnormal motility which were missed by routine HRM. If incorporated into routine practice, we may be able to objectively detect about 50% more patients with dysphagia which remain undetected currently.
980 BRAVO Wireless Esophageal pH Monitoring: A More Cost-Effective Approach Than Empiric Proton-Pump Inhibitor Therapy for Suspected Gastroesophageal Reflux Disease Cheguevara Afaneh, Veronica Zoghbi, Brendan M. Finnerty, Anna Aronova, Thomas Ciecierega, Carl V. Crawford, Thomas J. Fahey, Rasa Zarnegar Introduction: Early referral for esophageal pH monitoring via transnasal catheter has been shown to be more cost-effective than empiric proton-pump inhibitor (PPI) therapy to diagnose gastroesophageal reflux disease (GERD); however, the relative cost-effectiveness may be negated by the variable sensitivity, inconvenience & discomfort. We hypothesize that early referral for BRAVO esophageal pH monitoring will also demonstrate substantial cost-savings compared to empiric PPI therapy given the superior sensitivity and comfort. Methods: We reviewed 100 consecutive patients who underwent BRAVO esophageal pH monitoring with Demeester scoring for suspected GERD at our institution. Indications included both esophageal and extra-esophageal symptoms. A BRAVO cost model was generated based on the procedural cost and subsequent medical treatment dictated by the results. Calculations were performed assuming 75%, 85%, and 95% sensitivity of BRAVO esophageal pH monitoring. Cost savings analyses were performed for both esophageal & extra-esophageal symptoms. A cost equivalence calculation was performed to investigate how many weeks of empiric PPI therapy (low-dose generic PPI and high-dose name-brand PPI) would equate to the cost of BRAVO placement. Results: Eighty-seven patients were available for analysis. Mean age was 50 ± 14.3 years and 67% of patients were female. The median number of weeks of PPI use prior to referral was 215 (range 0-520). Overall, 43 patients (49%) had BRAVO results diagnosing GERD; 98% had esophageal symptoms. For patients with negative BRAVO studies (51%), a median of 113 (0-520) weeks of unnecessary PPI therapy occurred. Assuming 75% sensitivity, estimated costs savings of early BRAVO placement compared to empiric therapy beyond 8 weeks were $1,048 to $12,302 per patient, for low-dose generic and high-dose name-brand PPI, respectively. For patients with extra-esophageal symptoms, cost savings ranged from $2,948 to $24,567 per patient (Table 1A). Assuming 95% sensitivity, estimated costs savings of early BRAVO placement ranged from $1,598 to $15,853 per patient. For patients with extra-esophageal symptoms, cost savings ranged from $4,004 to $31,389 per patient. Assuming all of these patients were to undergo endoscopy given their symptoms, we have included the cost savings tailored to only include the cost of BRAVO placement and analysis (Table 1B). The cost equivalence of PPI therapy to BRAVO placement is 36 weeks for low-dose generic PPI and 6 weeks for high-dose name brand PPI. Conclusions: BRAVO testing is more cost-effective than prolonged empiric medical management for GERD. Given that most patients undergo EGD during the work-up for GERD, the placement of a BRAVO is a cost effective diagnostic modality when incorporated early in the treatment algorithm.
Flowchart illustrating subgrouping of study population based on symptoms and results of manometric testing
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Outcome Comparison of Elective vs. Acute Presentation of Giant Type III and IV Paraesophageal Hernia in a High Volume Center Kamran Mohiuddin, Michal Hubka, Donald Low
Is Hiatal Herniation After Transhiatal Esophagectomy an Underreported Complication? Oscar M. Crespin, Farhood Farjah, Carlos Cuevas, Analisa Armstrong, Bryan T. Kim, Ana V. Martin, Carlos A. Pellegrini, Brant Oelchlanger
Introduction: Although rare in the general population, Type III and IV paraesophageal hernias (PEH) are increasingly seen in older patients, especially women. These hernias produce a wide variety of symptoms but a component will present acutely with incarceration or obstruction. Outcomes of treatment of acute presentations have historically been inferior to elective repair. Methods: A prospective IRB approved database was used to retrospectively review all patients undergoing PEH repair between 2000-2014. Demographic, presenting factors and outcomes were compared between patient presenting for acute repair (AR) and those undergoing elective repair (ER). Results: 469 consecutive patients underwent surgical repair during this study period, 39 acute (8.3%), 430 elective. In patients presenting acutely, 4 (10%) required immediate surgery (2 perforations, 2 localized vascular compromise), 35 presented with acute incarceration and were treated with endoscopic or radiographic guided decompression prior to surgery. Patients presenting acutely were older (71.5 vs. 67.8), decreased BMI (28.3 vs. 30.2), had less preoperative heartburn (p=.01), regurgitation (p= .01) and dysphagia but a higher incidence of intermittent chest pain (p=.02). Mean Charlson
SSAT Abstracts
Introduction: Although hiatal herniation after esophagectomy (HHAE) is often considered an acute complication, improved patient survival as a result of early detection and multimodality treatment has led to an increasing number of reports of late presentation of HHAE. The aims of this study were to describe the overall incidence and presentation of hiatal hernias after transhiatal esophagectomy (THE). Methods: A retrospective cohort study (20042013) was performed of esophageal cancer patients who underwent THE. An expert radiologist independently reviewed all available post-operative computed tomography imaging to determine the presence or absence of HHAE regardless of the original radiology report. A time-to-event competing risk analysis was performed to estimate the cumulative incidence of HHAE. Results: There were 192 patients with THE during this period: median age 63, 83% men, median body mass index 26, 24% prior history of abdominal hernia, 83% stage II-III, and 67% induction therapy. The two-year cumulative incidence of HHAE was 14%
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comorbidity score, incidence of Type IV hernias (28% vs. 14%) and presentation of intrathoracic stomach >75% (60% vs. 43%) were all more common in the acute group. Operations were longer (174 vs. 154 min.) but blood loss was similar. In AR, mean length of hospital stay was higher (5.72 vs. 4.4 days), median (4 vs 4). There was no difference in perioperative complications on incidence of readmissions. One patient in the ER group died, overall mortality 0.2%. Conclusions: Acute presentation associated with PEH can be managed successfully with comparable outcomes to elective operations in high volume centers. Many patients can and should be treated with guided decompression for acute incarceration and obstruction. Patients with large PEH and recurrent chest pain should routinely be considered for elective repair.
Adjunctive Multiple Rapid Swallows Increases Sensitivity of High Resolution Manometry in Patients With Dysphagia Shunsuke Akimoto, Se Ryung Yamamoto, Harit Kapoor, Tommy H. Lee, sumeet K. mittal
SSAT Abstracts
Introduction Patients with dysphagia are assessed with normal High Resolution Manometry (HRM) , the current gold standard. Recently, provocative Multiple Rapid Swallow technique (MRS) has been reported to provide additional detail in characterization of the esophageal transit. The aim of this study is to compare the test-characteristics of HRM with adjunctive MRS in the detection of patients with dysphagia. Methods All patients undergoing HRM evaluation between June 2014 to October 2014 were additionaly administered the MRS. Patients swallowed four 2ml water boluses, each four seconds apart. The parameters measured were Post-Deglutitory Inhibition(PDI) and the success of Rebound Esophageal Contraction(REC) using the 30mmHg isobaric contour. PDI was considered complete unless a contraction measuring > 3cm was identified, wherein it was considered incomplete. REC was considered failed when there was no smooth muscle contraction, the intersegmental trough was >3cm or when the contraction was interrupted for >3cm. We compared the sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) of HRM alone and with adjunctive MRS in the detection of dysphagia. Patients with known achalasia or previous foregut surgery were excluded. Results Sixty-five patients underwent HRM during the study period, of which 46 met the inclusion criteria. The mean age of the group was 57 years with 19 (41.3%) males. Twenty-nine (63%) patients had dysphagia. Those with and without dysphagia had similar mean age (57.2 vs. 56.7) and gender distribution (males%; 37.9% vs. 47.1%). On HRM, patients with and without dysphagia had similar Integrated relaxation pressures (IRP) (9.2 vs. 9.9; p=0.771) and Distal contractile integral (DCI) (2821 vs. 2552; p=0.671). In patients with dysphagia, REC failure (65.52%) was more common than abnormal PDI (37.9%) and outflow obstruction (IRP^15) (13.8%). Patients with dysphagia had significantly higher rate of REC failure when compared to patients without dysphagia (65.5% vs. 35.3%; p=0.047) but PDI was not statistically different (37.9% vs. 23.5%; p=0.315). The Se, PPV and NPV of REC component of the test was much higher than the PDI component (Se; 65.5% vs. 37.9%, PPV; 76% vs. 73.3%; NPV: 52.4% vs. 41.9%). The Sp of the PDI component was marginally higher than that of the REC (76.5% vs. 64.7%). Overall, MRS, especially the REC component stood out as a better indication of dysphagia than conventional HRM alone (Se; 41.4%, Sp; 64.7%, PPV; 66.7%, NPV; 39.3%). Conclusion MRS seems to be a valuable adjunct in the evaluation of dysphagia. It identified an additional 10 patients as having abnormal motility which were missed by routine HRM. If incorporated into routine practice, we may be able to objectively detect about 50% more patients with dysphagia which remain undetected currently.
980 BRAVO Wireless Esophageal pH Monitoring: A More Cost-Effective Approach Than Empiric Proton-Pump Inhibitor Therapy for Suspected Gastroesophageal Reflux Disease Cheguevara Afaneh, Veronica Zoghbi, Brendan M. Finnerty, Anna Aronova, Thomas Ciecierega, Carl V. Crawford, Thomas J. Fahey, Rasa Zarnegar Introduction: Early referral for esophageal pH monitoring via transnasal catheter has been shown to be more cost-effective than empiric proton-pump inhibitor (PPI) therapy to diagnose gastroesophageal reflux disease (GERD); however, the relative cost-effectiveness may be negated by the variable sensitivity, inconvenience & discomfort. We hypothesize that early referral for BRAVO esophageal pH monitoring will also demonstrate substantial cost-savings compared to empiric PPI therapy given the superior sensitivity and comfort. Methods: We reviewed 100 consecutive patients who underwent BRAVO esophageal pH monitoring with Demeester scoring for suspected GERD at our institution. Indications included both esophageal and extra-esophageal symptoms. A BRAVO cost model was generated based on the procedural cost and subsequent medical treatment dictated by the results. Calculations were performed assuming 75%, 85%, and 95% sensitivity of BRAVO esophageal pH monitoring. Cost savings analyses were performed for both esophageal & extra-esophageal symptoms. A cost equivalence calculation was performed to investigate how many weeks of empiric PPI therapy (low-dose generic PPI and high-dose name-brand PPI) would equate to the cost of BRAVO placement. Results: Eighty-seven patients were available for analysis. Mean age was 50 ± 14.3 years and 67% of patients were female. The median number of weeks of PPI use prior to referral was 215 (range 0-520). Overall, 43 patients (49%) had BRAVO results diagnosing GERD; 98% had esophageal symptoms. For patients with negative BRAVO studies (51%), a median of 113 (0-520) weeks of unnecessary PPI therapy occurred. Assuming 75% sensitivity, estimated costs savings of early BRAVO placement compared to empiric therapy beyond 8 weeks were $1,048 to $12,302 per patient, for low-dose generic and high-dose name-brand PPI, respectively. For patients with extra-esophageal symptoms, cost savings ranged from $2,948 to $24,567 per patient (Table 1A). Assuming 95% sensitivity, estimated costs savings of early BRAVO placement ranged from $1,598 to $15,853 per patient. For patients with extra-esophageal symptoms, cost savings ranged from $4,004 to $31,389 per patient. Assuming all of these patients were to undergo endoscopy given their symptoms, we have included the cost savings tailored to only include the cost of BRAVO placement and analysis (Table 1B). The cost equivalence of PPI therapy to BRAVO placement is 36 weeks for low-dose generic PPI and 6 weeks for high-dose name brand PPI. Conclusions: BRAVO testing is more cost-effective than prolonged empiric medical management for GERD. Given that most patients undergo EGD during the work-up for GERD, the placement of a BRAVO is a cost effective diagnostic modality when incorporated early in the treatment algorithm.
Flowchart illustrating subgrouping of study population based on symptoms and results of manometric testing
979 981
Outcome Comparison of Elective vs. Acute Presentation of Giant Type III and IV Paraesophageal Hernia in a High Volume Center Kamran Mohiuddin, Michal Hubka, Donald Low
Is Hiatal Herniation After Transhiatal Esophagectomy an Underreported Complication? Oscar M. Crespin, Farhood Farjah, Carlos Cuevas, Analisa Armstrong, Bryan T. Kim, Ana V. Martin, Carlos A. Pellegrini, Brant Oelchlanger
Introduction: Although rare in the general population, Type III and IV paraesophageal hernias (PEH) are increasingly seen in older patients, especially women. These hernias produce a wide variety of symptoms but a component will present acutely with incarceration or obstruction. Outcomes of treatment of acute presentations have historically been inferior to elective repair. Methods: A prospective IRB approved database was used to retrospectively review all patients undergoing PEH repair between 2000-2014. Demographic, presenting factors and outcomes were compared between patient presenting for acute repair (AR) and those undergoing elective repair (ER). Results: 469 consecutive patients underwent surgical repair during this study period, 39 acute (8.3%), 430 elective. In patients presenting acutely, 4 (10%) required immediate surgery (2 perforations, 2 localized vascular compromise), 35 presented with acute incarceration and were treated with endoscopic or radiographic guided decompression prior to surgery. Patients presenting acutely were older (71.5 vs. 67.8), decreased BMI (28.3 vs. 30.2), had less preoperative heartburn (p=.01), regurgitation (p= .01) and dysphagia but a higher incidence of intermittent chest pain (p=.02). Mean Charlson
SSAT Abstracts
Introduction: Although hiatal herniation after esophagectomy (HHAE) is often considered an acute complication, improved patient survival as a result of early detection and multimodality treatment has led to an increasing number of reports of late presentation of HHAE. The aims of this study were to describe the overall incidence and presentation of hiatal hernias after transhiatal esophagectomy (THE). Methods: A retrospective cohort study (20042013) was performed of esophageal cancer patients who underwent THE. An expert radiologist independently reviewed all available post-operative computed tomography imaging to determine the presence or absence of HHAE regardless of the original radiology report. A time-to-event competing risk analysis was performed to estimate the cumulative incidence of HHAE. Results: There were 192 patients with THE during this period: median age 63, 83% men, median body mass index 26, 24% prior history of abdominal hernia, 83% stage II-III, and 67% induction therapy. The two-year cumulative incidence of HHAE was 14%
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