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Mo1158 MRI T2 Relaxometry to Image Fibrosis in Patients With Crohn's Disease
AGA Abstracts
modified to begin at the antrum to avoid the need for retroflexion. Once the fundus was reached and closed, it was sutured to the lower esophageal sphincter. In the second group, the tissue plication sequence was modified to triangular plications in the posterior wall of the stomach, greater curvature, and anterior curvature to prevent bleeding from obscuring the site of the next tissue purchase site. Means are reported with ±SEM. Results In the initial group of 5 patients, safety and feasibility were demonstrated. There were no significant adverse events. Procedure time was 3.48 ±0.5 hours. BMI changed from 37.4 ±1.9 kg/m2 at the time of the procedure to 34.8 ±1.5 kg/m2 after 5 months. The second group included 4 males and 19 females with mean age of 37.7 ±1.9 y. A median of 8 running sutures, each with 6-12 tissue purchases, was used per procedure. There were no significant adverse events. Average procedure time was 120 min (range 95-240 min). Patients had mean BMI of 34.2 ±1.1 kg/m2 at the time of the procedure. Weight loss at 1 month was 8.0 ±0.5 kg; weight loss at 6 months was 14.5 ±2.2 kg and BMI had decreased to 28.9 kg/m2; weight loss at 1 year was 13.1 ±1.3 kg and BMI had decreased to 29.4 kg/m2. Conclusions Initial human cases using Apollo OverStitch for endoscopic sleeve gastroplasty demonstrated safety and efficacy. The procedure was significantly refined during these cases, with the final method achieving gastric volume reduction with marked improvements in procedure time and technical demand. Follow-up revealed meaningful weight loss. Further study is ongoing.
Mo1158 MRI T2 Relaxometry to Image Fibrosis in Patients With Crohn's Disease Christine M. Breynaert, Tom Dresselaers, Ronald Peeters, Ilse Roebben, Kristel Van Steen, Tim Vanuytsel, Vera Ballet, Marc Ferrante, Severine Vermeire, Paul J. Rutgeerts, Uwe Himmelreich, Steven Dymarkowski, Dirk Vanbeckevoort, Gert A. Van Assche BACKGROUND: Non-invasive imaging tools that can assess connective tissue changes and can be applied repetitively, would be a major asset for the management of IBD, especially for the study of treatment efficacy and to predict treatment response. In vivo μMRI T2 relaxometry, a non-invasive imaging tool, allows to discriminate between acute and chronic phases of bowel wall inflammation and fibrosis in murine DSS colitis (Breynaert et al, Plos One 2013). We aimed at assessing the value of MRI T2 relaxometry in patients with Crohn's disease (CD). METHODS: To define the normal value of T2 intensity of the rectum, healthy volunteers had a pelvic MRI with acquisition of high resolution T2 weighted images and T2 relaxometry. CD patients in whom a pelvic MRI was indicated for assessment of CD activity were recruited after informed consent for an additional T2 relaxometry. On the T2 map of the pelvis, the rectum was identified on 3 cross-sections per patient and delineated. Within these regions of interest the distribution of the T2 times between 0 and 250 ms was determined using ImageJ. The study was approved by the Ethics Committee of the University Hospitals of Leuven (S53186 - Belgian number B322201111559). RESULTS: In total, 18 healthy volunteers (10 M) and 17 patients (4 M) were included, 6 patients were excluded because of claustrophobia or early discontinuation of scanning. The mean T2 of the rectum was not significantly different (p=0.119) between patients (113.0 ms (109.0-120.4)) and volunteers (118.3 ms (115.4-121.3)). However, analysis of the T2 map of the rectum of CD patients showed a broadening of the histogram to lower values compared to healthy volunteers (p=0.002). CONCLUSION: T2 relaxometry of the pelvis in patients with CD identifies a histogram shift compared to healthy volunteers consistent with the changes observed in chronic DSS colitis. The data suggest that MRI T2 relaxometry is a promising tool to assess fibrosis in CD. Further investigation of this non-invasive, radiation and IV contrast free imaging tool is warranted.
Mo1156 The Pursestring Technique for Endoscopic Transoral Outlet Reduction Nitin Kumar, Christopher C. Thompson Background Weight regain after Roux-en-Y gastric bypass (RYGB) is correlated with dilated gastrojejunal anastomosis (GJA). Transoral outlet reduction (TORe), using interrupted stitches, was shown to be safe and effective in arresting weight regain in a randomized controlled trial. A new pursestring suturing technique has since been developed, to better distribute the forces applied to tissue. Additionally, final aperture size is better controlled as suture is tightened over a controlled radial expansion (CRE) endoscopic balloon. Aim To analyze the relative effectiveness of TORe using the pursestring for therapy of weight regain in post-RYGB patients. Methods Patients were enrolled in a prospective database. All consecutive pursestring TORe procedures performed using the Apollo OverStitch (Apollo Endosurgery, Austin, TX), with over 6 months of clinical follow-up, were included. Percent excess weight loss (%EWL) was determined for each patient. All means are reported as mean ± SEM. Correlations are reported as Pearson's correlation coefficient. Results 26 patients (age 50.3 ±1.4 yr, 6M/33F) had pre-RYGB BMI of 49.0 ±1.3 kg/m2. Postoperative nadir BMI was 29.3 ±1.0 kg/m2. TORe was performed 11.1 ±3.1 years after RYGB, with weight regain resulting in BMI of 37.9 ±1.1 kg/m2 at time of TORe. At the time of TORe, mean GJA aperture was 24.8 ±1.1 mm and mean pouch length was 4.5 ±0.3 cm. The margin of the GJA was ablated with argon plasma coagulation. Using a single suture, 7.7 ±0.4 stitches were placed around the margin of the GJA in a continuous ring. The suture was tightened and cinched over a CRE balloon inflated to a diameter of approximately 10-12 mm. A mean 1.9 ±0.2 stitches were placed in the gastric pouch to reduce gastric pouch volume. There were no major adverse events associated with the procedure. Mean weight loss at 6 months was 10.2 ±1.8 kg, at 1 year was 9.4 ±3.0 kg, and 18 months was 11.5 ±3.4 kg. Reduction in GJA aperture (in mm) significantly correlated with weight loss at 6 months (r=0.55, p=0.028) and 1 year (r=0.58, p=0.048). Two patients were lost to followup at the 1-year timepoint and three patients were lost at the 18-month timepoint. Conclusion The pursestring technique for TORe was applied safely and effectively in this study, resulting in durable weight loss. Weight loss correlated with degree of GJA aperture reduction. Unlike the interrupted technique utilized in prior studies, this new method allows precise outlet sizing and circumferential reinforcement, which may lead to more consistent results. Mo1157 Effects of Laparoscopic Sleeve Gastrectomy on Gastric Emptying Time and Residual Antrum Peristalsis Assessed Through Magnetic Resonance Barbara Paolini, Irene Del Ciondolo, Elisa Lapini, Lucia Ceccarelli, Katia Gennai, Massimo Vincenzi, Andrea Tirone, Salvatore Francesco Carbone, Claudia Bellini, Giiuseppe Vuolo In the present study we evaluated a group of 20 patients (BMI 44,41 ± 4.76 Kg/m2, mean age 47 years old) after bariatric surgery (Laparoscopic Sleeve Gastrectomy LSG) who have been submitted to a magnetic resonance (MR) before surgery and a MR 8 months after surgery. It was recommended 6-8 hours of fasting before MR: all the patients before surgery had to eat 400 ml of vanilla pudding with the addition of 5 ml of Gd-DTPA immediately before the examination, whereas after surgery they had to eat 125 ml of vanilla pudding with the addition of 5 ml of Gd-DTPA, The examination was conducted in supine position, using a 1,5 T MR system and an 8 channel phased array coil. We got T1 dependent 3D gradient-echo sequences (TR/TE 3,4/1,6; 256x224 matrix; FOV 44x44 cm; thickness/gap 5/0; NSA 0.73) on the axial plane at the beginning of the examination (T0) and after 30 minutes. Every 5 minutes per 30 minutes we executed CINE FIESTA sequences (TR/TE 4.3/1.9 msec; 192x320 matrix, FOV 38x38cm; thickness/gap 4/0; NSA 1) on the oblique plane in order to obtain a better view of the gastric antrum. We attributed 2 volume values to time T0 (V0) and after 30 minutes (V30) and we calculated gastric volume half-life (T1/ 2) using this formula T1/2 = [30 x (V0/2)]/(V0-V30). All the patients well tolerate the examination. We noticed a significant increase in antrum peristalsis after 30 minutes (p<0,0001) in the preoperative phase, but this parameter didn't change in patients after LSG (0,84) The aim of the present study was the MR evaluation of gastric emptying time and residual antrum peristalsis in patients submitted to LSG. After LSG there is a statistical significant increase of antrum peristalsis with a reduction of gastric emptying time. These improvements can be attributed to the functional anatomy modification, to the gastric volume restriction, to the gastric innervation and coordination changes and also to GPL1 secretion increasing LSG related. Results (*two tailed test for speed).
AGA Abstracts
Histogram of the rectum of healthy volunteers and CD patients Mo1159 Contrast Enhanced Ultrasound as a Point-of-Care Technique in Complicated Crohn's Disease Patients Emma Calabrese, Francesca Zorzi, Elisa Stasi, Elisabetta Lolli, Sara Onali, Patrizio Scarozza, Giovanna Condino, Carmelina Petruzziello, Livia Biancone, Francesco Pallone Background. Crohn's disease (CD) is associated with penetrating complications such as phlegmons and intra-abdominal abscesses. As the management of the patients influenced by the presence of such complications, a readily available tool for the diagnosis of extramural complications in CD is needed. Preliminary findings suggest that the assessment of vascularity within intra-abdominal masses may distinguish between phlegmons and abscesses. Aim of our study was to evaluate the use of contrast enhanced ultrasound (CEUS) to distinguish between phlegmons and intra-abdominal abscesses in CD patients as a point-of-care technique. Methods. From November 2011, consecutive patients with complicated CD were enrolled. Indications of patient assessments by CEUS were symptoms, signs and biochemical exams indicating penetrating behavior (abdominal pain, mass, fever, elevated CRP and leukocytosis). A total of 22 CD pts (14 M; median age 27 yrs, range 18-75; disease duration: median 54 mos, range 1-564; CD site: ileal in 13 pts, ileo-colonic in 9 pts; CD behavior: penetrating in 20 pts, stricturing in 2 pts; previous ileocolonic resection in 9 pts) were included. Clinical evaluation by an IBD expert and other cross sectional imaging techniques (MR and CT) were considered as the standard. Results. CEUS detected abscesses in 9 and phlegmons in 12 pts. One patient had an unspecified lesion that was diagnosed as metastasis by PET. Six out of 9 abscesses were confirmed by CT-Enteroclysis and these pts underwent
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modified to begin at the antrum to avoid the need for retroflexion. Once the fundus was reached and closed, it was sutured to the lower esophageal sphincter. In the second group, the tissue plication sequence was modified to triangular plications in the posterior wall of the stomach, greater curvature, and anterior curvature to prevent bleeding from obscuring the site of the next tissue purchase site. Means are reported with ±SEM. Results In the initial group of 5 patients, safety and feasibility were demonstrated. There were no significant adverse events. Procedure time was 3.48 ±0.5 hours. BMI changed from 37.4 ±1.9 kg/m2 at the time of the procedure to 34.8 ±1.5 kg/m2 after 5 months. The second group included 4 males and 19 females with mean age of 37.7 ±1.9 y. A median of 8 running sutures, each with 6-12 tissue purchases, was used per procedure. There were no significant adverse events. Average procedure time was 120 min (range 95-240 min). Patients had mean BMI of 34.2 ±1.1 kg/m2 at the time of the procedure. Weight loss at 1 month was 8.0 ±0.5 kg; weight loss at 6 months was 14.5 ±2.2 kg and BMI had decreased to 28.9 kg/m2; weight loss at 1 year was 13.1 ±1.3 kg and BMI had decreased to 29.4 kg/m2. Conclusions Initial human cases using Apollo OverStitch for endoscopic sleeve gastroplasty demonstrated safety and efficacy. The procedure was significantly refined during these cases, with the final method achieving gastric volume reduction with marked improvements in procedure time and technical demand. Follow-up revealed meaningful weight loss. Further study is ongoing.
Mo1158 MRI T2 Relaxometry to Image Fibrosis in Patients With Crohn's Disease Christine M. Breynaert, Tom Dresselaers, Ronald Peeters, Ilse Roebben, Kristel Van Steen, Tim Vanuytsel, Vera Ballet, Marc Ferrante, Severine Vermeire, Paul J. Rutgeerts, Uwe Himmelreich, Steven Dymarkowski, Dirk Vanbeckevoort, Gert A. Van Assche BACKGROUND: Non-invasive imaging tools that can assess connective tissue changes and can be applied repetitively, would be a major asset for the management of IBD, especially for the study of treatment efficacy and to predict treatment response. In vivo μMRI T2 relaxometry, a non-invasive imaging tool, allows to discriminate between acute and chronic phases of bowel wall inflammation and fibrosis in murine DSS colitis (Breynaert et al, Plos One 2013). We aimed at assessing the value of MRI T2 relaxometry in patients with Crohn's disease (CD). METHODS: To define the normal value of T2 intensity of the rectum, healthy volunteers had a pelvic MRI with acquisition of high resolution T2 weighted images and T2 relaxometry. CD patients in whom a pelvic MRI was indicated for assessment of CD activity were recruited after informed consent for an additional T2 relaxometry. On the T2 map of the pelvis, the rectum was identified on 3 cross-sections per patient and delineated. Within these regions of interest the distribution of the T2 times between 0 and 250 ms was determined using ImageJ. The study was approved by the Ethics Committee of the University Hospitals of Leuven (S53186 - Belgian number B322201111559). RESULTS: In total, 18 healthy volunteers (10 M) and 17 patients (4 M) were included, 6 patients were excluded because of claustrophobia or early discontinuation of scanning. The mean T2 of the rectum was not significantly different (p=0.119) between patients (113.0 ms (109.0-120.4)) and volunteers (118.3 ms (115.4-121.3)). However, analysis of the T2 map of the rectum of CD patients showed a broadening of the histogram to lower values compared to healthy volunteers (p=0.002). CONCLUSION: T2 relaxometry of the pelvis in patients with CD identifies a histogram shift compared to healthy volunteers consistent with the changes observed in chronic DSS colitis. The data suggest that MRI T2 relaxometry is a promising tool to assess fibrosis in CD. Further investigation of this non-invasive, radiation and IV contrast free imaging tool is warranted.
Mo1156 The Pursestring Technique for Endoscopic Transoral Outlet Reduction Nitin Kumar, Christopher C. Thompson Background Weight regain after Roux-en-Y gastric bypass (RYGB) is correlated with dilated gastrojejunal anastomosis (GJA). Transoral outlet reduction (TORe), using interrupted stitches, was shown to be safe and effective in arresting weight regain in a randomized controlled trial. A new pursestring suturing technique has since been developed, to better distribute the forces applied to tissue. Additionally, final aperture size is better controlled as suture is tightened over a controlled radial expansion (CRE) endoscopic balloon. Aim To analyze the relative effectiveness of TORe using the pursestring for therapy of weight regain in post-RYGB patients. Methods Patients were enrolled in a prospective database. All consecutive pursestring TORe procedures performed using the Apollo OverStitch (Apollo Endosurgery, Austin, TX), with over 6 months of clinical follow-up, were included. Percent excess weight loss (%EWL) was determined for each patient. All means are reported as mean ± SEM. Correlations are reported as Pearson's correlation coefficient. Results 26 patients (age 50.3 ±1.4 yr, 6M/33F) had pre-RYGB BMI of 49.0 ±1.3 kg/m2. Postoperative nadir BMI was 29.3 ±1.0 kg/m2. TORe was performed 11.1 ±3.1 years after RYGB, with weight regain resulting in BMI of 37.9 ±1.1 kg/m2 at time of TORe. At the time of TORe, mean GJA aperture was 24.8 ±1.1 mm and mean pouch length was 4.5 ±0.3 cm. The margin of the GJA was ablated with argon plasma coagulation. Using a single suture, 7.7 ±0.4 stitches were placed around the margin of the GJA in a continuous ring. The suture was tightened and cinched over a CRE balloon inflated to a diameter of approximately 10-12 mm. A mean 1.9 ±0.2 stitches were placed in the gastric pouch to reduce gastric pouch volume. There were no major adverse events associated with the procedure. Mean weight loss at 6 months was 10.2 ±1.8 kg, at 1 year was 9.4 ±3.0 kg, and 18 months was 11.5 ±3.4 kg. Reduction in GJA aperture (in mm) significantly correlated with weight loss at 6 months (r=0.55, p=0.028) and 1 year (r=0.58, p=0.048). Two patients were lost to followup at the 1-year timepoint and three patients were lost at the 18-month timepoint. Conclusion The pursestring technique for TORe was applied safely and effectively in this study, resulting in durable weight loss. Weight loss correlated with degree of GJA aperture reduction. Unlike the interrupted technique utilized in prior studies, this new method allows precise outlet sizing and circumferential reinforcement, which may lead to more consistent results. Mo1157 Effects of Laparoscopic Sleeve Gastrectomy on Gastric Emptying Time and Residual Antrum Peristalsis Assessed Through Magnetic Resonance Barbara Paolini, Irene Del Ciondolo, Elisa Lapini, Lucia Ceccarelli, Katia Gennai, Massimo Vincenzi, Andrea Tirone, Salvatore Francesco Carbone, Claudia Bellini, Giiuseppe Vuolo In the present study we evaluated a group of 20 patients (BMI 44,41 ± 4.76 Kg/m2, mean age 47 years old) after bariatric surgery (Laparoscopic Sleeve Gastrectomy LSG) who have been submitted to a magnetic resonance (MR) before surgery and a MR 8 months after surgery. It was recommended 6-8 hours of fasting before MR: all the patients before surgery had to eat 400 ml of vanilla pudding with the addition of 5 ml of Gd-DTPA immediately before the examination, whereas after surgery they had to eat 125 ml of vanilla pudding with the addition of 5 ml of Gd-DTPA, The examination was conducted in supine position, using a 1,5 T MR system and an 8 channel phased array coil. We got T1 dependent 3D gradient-echo sequences (TR/TE 3,4/1,6; 256x224 matrix; FOV 44x44 cm; thickness/gap 5/0; NSA 0.73) on the axial plane at the beginning of the examination (T0) and after 30 minutes. Every 5 minutes per 30 minutes we executed CINE FIESTA sequences (TR/TE 4.3/1.9 msec; 192x320 matrix, FOV 38x38cm; thickness/gap 4/0; NSA 1) on the oblique plane in order to obtain a better view of the gastric antrum. We attributed 2 volume values to time T0 (V0) and after 30 minutes (V30) and we calculated gastric volume half-life (T1/ 2) using this formula T1/2 = [30 x (V0/2)]/(V0-V30). All the patients well tolerate the examination. We noticed a significant increase in antrum peristalsis after 30 minutes (p<0,0001) in the preoperative phase, but this parameter didn't change in patients after LSG (0,84) The aim of the present study was the MR evaluation of gastric emptying time and residual antrum peristalsis in patients submitted to LSG. After LSG there is a statistical significant increase of antrum peristalsis with a reduction of gastric emptying time. These improvements can be attributed to the functional anatomy modification, to the gastric volume restriction, to the gastric innervation and coordination changes and also to GPL1 secretion increasing LSG related. Results (*two tailed test for speed).
AGA Abstracts
Histogram of the rectum of healthy volunteers and CD patients Mo1159 Contrast Enhanced Ultrasound as a Point-of-Care Technique in Complicated Crohn's Disease Patients Emma Calabrese, Francesca Zorzi, Elisa Stasi, Elisabetta Lolli, Sara Onali, Patrizio Scarozza, Giovanna Condino, Carmelina Petruzziello, Livia Biancone, Francesco Pallone Background. Crohn's disease (CD) is associated with penetrating complications such as phlegmons and intra-abdominal abscesses. As the management of the patients influenced by the presence of such complications, a readily available tool for the diagnosis of extramural complications in CD is needed. Preliminary findings suggest that the assessment of vascularity within intra-abdominal masses may distinguish between phlegmons and abscesses. Aim of our study was to evaluate the use of contrast enhanced ultrasound (CEUS) to distinguish between phlegmons and intra-abdominal abscesses in CD patients as a point-of-care technique. Methods. From November 2011, consecutive patients with complicated CD were enrolled. Indications of patient assessments by CEUS were symptoms, signs and biochemical exams indicating penetrating behavior (abdominal pain, mass, fever, elevated CRP and leukocytosis). A total of 22 CD pts (14 M; median age 27 yrs, range 18-75; disease duration: median 54 mos, range 1-564; CD site: ileal in 13 pts, ileo-colonic in 9 pts; CD behavior: penetrating in 20 pts, stricturing in 2 pts; previous ileocolonic resection in 9 pts) were included. Clinical evaluation by an IBD expert and other cross sectional imaging techniques (MR and CT) were considered as the standard. Results. CEUS detected abscesses in 9 and phlegmons in 12 pts. One patient had an unspecified lesion that was diagnosed as metastasis by PET. Six out of 9 abscesses were confirmed by CT-Enteroclysis and these pts underwent
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