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Role of endoscopic ultrasound in patients with Barrett's esophagus and high grade dysplasia
ESOPHAGUS $205 SOMATOSTATIN ALONE OR COMBINED WITH EMERGENCY SCLEROTHERAPY F O R ACUTE VARICEAL BLEEDING. J.Ortiz, CA/illanuexa,M.SAbat,G.Soriano, S.S/dnz, J.Velasco, S.Ricart, L.Kolle, l.Balanz6. Bleeding Unit.GastroenterologyDepartment. Hospital Sant Pau. Barcelona. Spain. Comparative studies have shown that both somatostatin (SM) and octreotide are as effective as endoscopic sclerotherapy (ES) in the treatment of acute variceal bleeding, and that the combined administration of SM with ES is more effective than ES alone. The aim of the present study was to assess whether combined therapy with SM and ES is also superior to SM alone for the control of acute variceal bleeding and the prevention of early rebleeding. METHODS: During a 2-year period, all patients admitted to our unit with hematemesis and/or melena and in who cirrhosis and portal hypertension were suspected, received a continuous infusion of SM (250 Ixg/hr, with additional bolus of 250p, g every 6 hr). Emergency endoscopy was performed 1 to 5 hours after starting SM When endoscopy disclosed variceal bleeding , patients were randomized to ES or no ES, which was carried out during the same endoscopic procedure (by intravariceal injection of 10 to 20 ml of 5% ethanolamine). In both groups, SM infusion was continued for 5 days. Randomization was stratified for Pugh's class. Variceal bleeding was diagnosed when there was: 1) active bleeding, or 2) a clot or a fibrin plug over a varix, or 31 varices with no other potential source of bleeding. Therapeutic failure was defined if there was: 1) persistent bleeding (within the first 6hr. after endoscopy) or 2) early reblceding (during a 5day period). RESULTS: 97 consecutive bleeding episodes, which occured in 85 patients, were included (26% occurred in Child-Pugh's class C patients and 43% had alcoholic cirrhosis). 48 episodes were treated with SM alone and 49 with SM plus ES. Both groups were well matched for baseline data. Therapeutic failure occurred in 21 cases of the SM group (44%) and in 9 cases of the SM plus ES group (18%) (P< 0.01.95% CI= 7% to 43%h persistent bleeding in 7 (14%) vs. 2 (4%) (PNS, 95% CI= -2% to 19%) and early rebleeding in 14 (29%) vs. 7 (14% ~(P< 0.05. 95% CI = 1% to 33%). There was a tendency towards higher transfusion requirements in SM group. Major complications were more frequent with the combined therapy (8% vs 22%). 15% of the patients died whithin a 30-day period, without significant difference between both groups. CONCLUSIONS: Combined therapy with emergency ES and SM is more effective than SM alone, for the initial control of acute variceal bleeding and for the prevention of early rebleeding. However. survival is not improved and there is a trend towards a greater complications rate with combined therapy.
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PHOTODYNAMIC THERAPY A L O N E OR WITH THERMAL A B L A T I O N ELIMINATES BARRETT'S ESOPHAGUS. Ber,qein F. Overholt and Masoud Panjehpour, Thompson Cancer Survival Center, Knoxville. TN. PURPOSE. To determine if photodynamic therapy (PDT) alone or in combination with thermal ablation can eliminate Barrett's esophagus. This report presents the results in patients who were being treated with PDT for Barrett's dysplasia or early cancer as part of an ongoing study. METHODS. Seventy-one patients received PDT using sodium porfimer as the photosensitizer. Light (630nm) was delivered endoscopically using a diffuser or by a centering balloon technique. Lugors staining and 4 quadrant biopsies every 2 cm of treated areas were used to identify residual Barrett's mucosa during follow-up endoscopies. All patients were maintained on omeprazole. Follow-up ranged from 6-60 mos. RESULTS. Twenty-three patients had complete ablation of Barrett's mucosa. Eleven of the 23 patients (Barrett's mucosa length range of 2-10 cm; av 4.9 cml were treated with only PDT. Twelve of the 23 patients (Barrett's mucosa length range of 2-12 cm: av 6.9 cm) received PDT followed by contact Nd:YAG laser therapy to residual islands of Barrett's mucosa during follow-up endoscopies. Longer segments of Barrett's mucosa usually required Nd:YAG laser for total ablation although recent work with 5-7 cm centering balloons suggests less need for laser. CONCLUSIONS. PDT alone or in combination with thermal ablation eliminates Barrett's mucosa in selectec~ patients.
ROLE OF ENDOSCOPIC ULTRASOUND IN PATIENTS WITH BARRETT'S ESOPHAGUS AND H I G H GRADE DYSPLASIA. J. Parent. D.S. Levine, R.C. Haggitt, B.J. Reid, M.B Kimmey, Division of Gastroenterologyand Dept. of Pathology, University of Washington, Seattle, WA The detection of early malignancy in BarretX's esophagus remains a cbnlleagmg problem. The omtribution of endoscopic ultrasound (EUS) to the efficacy of endoscopic biopsy surveillance has not been clearly established. AIM: To determine if EUS detects occult adenocareinomas m patients found to have high grade dysplasia in endoscopic surveillance protocols. METHODS: 27 patients (4 females) enrolled in a university-based surveillance program for Barrett's esophagus and found to have high grade dysplasia un biopsy underweat 34 EUS exams. Endoscopic surveillance was performed at 3-6 month intervals with four quadrant biopsms every 1 cul throughout the length of the Barrett's esophagus. Additional biopsies were taken from visible nodules or ulcers. All patients were followed for at least 12 months or until they had smgery. The mean duration of high grade dysplasia was 15.5 months. The metal length of the Barrett's esophagus was 6.6 cm. Endoscopic findings included nodules (11), ulcers (3) and no mucosal lesions (20). EUS was performed using a radial scanning echo endoscope (Olympus GFM-3 or OF-UM20) in all patients. 13 patients were also examined using a 20 MHz linear or radial miniprobe. RESULTS: No abnormalities of the esophageal wall were seen in 27/34 EUS exams. 7 had focal thickening invelving only the mucosa (no disruption of layer 3); 6 of these had a lesion smm on endoscopy (4 nodules & 2 ulcers) and 1 had a normal endoscopy. Benign appearing lymph nodes were identified in 8 EUS exams. When water could be maimained in the lumen, all patiants examined with the miniprobe had thickening or irregularity of layer 2 without disruption of layer 3. Six patients had an esophagectomy within 2 months of the EUS exam and had only dysplasia on pathology. All other patiems remained under endoscopic surveillance; 8 of these underwem surgery 4 to 23 months after EUS, following the development of biopsy proven carcinoma. The 13 remaining patients have been followed for a mean of 27 months (range 15 to 65 months) with exmtinued dysplasia. Based cu these results the specificity of EUS for excluding the presence of carcinoma is 100% with a 95% confidence interval of 89% to 100%. CONCLUSION: EUS does not detect adenocarcinomas in patiants found to have high grade dysplasia on a comprehensive eadeacopic biopsy surveillance protocol for Barrett's esophagus. Sunographic abnormalities are seen primarily in patients with endoscopically visible lesions.
AB76
G A S T R O I N T E S T I N A L ENDOSCOPY
ACCURACY OF ENDOSCOPIC ULTRASOUND STAGING IN PATIENTS WITH BARRETT'S ESOPHAGUS AND INTRAMUCOSAL CARCINOMA. J. Parent, D.S. Levine, R.C. Hagght, D.E. Wood, B.J. Reid, MB. Kimmey, Division of Gastroemerolcgy, Depts of Pathology and Surgery, University of Washington, Seattle, WA The accuracy of endoscopic ultrasound (EUS) staging in patiems with Barrett's esophagus who are found to have intramucoeal carcinoma on endoscopy and biopsy has not been established. MM: To determine the accuracy of EUS staging in patients with Barrett's esophagus and biopsy provan lmramucusal carcinoma by comparing EUS findings m surgical pathology. METHODS: 30 patiants (3 females) with known Burrett's esophagus, found to have intramucosal carcinonm on biopsy, underwent EUS using a radial scanning echo endoscope (Olympus GFM-3 or GF-UM20). 10 patients were also examined using a 20 MI-h linear or radial miniprobe. All patients underwent esophagectomy within one month of the EUS exam. RESULTS: Endoscopic findings included nodules (19), ulcers (3) and no mucosal lesions (8) No abnormalities of the esophageal wall were seen in 16/30 radial EUS exun~, 7 had focal thickening involving only the mucosa (no disruption of layer 3), 7 had thickening of the mucoea and dismpticu of layer 3 suggesting invasion of the muscularis mucosae (m.m.) or of the submucosa. Benlgu appearing lymph nodes were identified in 10 EUS exams. EUS findings Surgical Patholoev normal thickened layer 2 disruption of layer 3 high grade dysplasia 9 3 0 intramucosal cercmoma 4 2 1 m.m. invasion 1 1 2 submucesal invasion 2 1 4 The sensitivity and specificity of EUS in the detection of musculatis mucusae or subraueosal invasion were 55% and 95% respectively. EUS and pathology did not reveal muscularis propria invasion or malignant lymph nodes in any patiem. All 10 exams with the miniprobe showed thickening or irregularity of layer 2 and 4 showed disruption of layer 3 with pathological confirmation of submucosal invasiun in 3/4 CONCLUSION: In patients with Barrett's esophagus and biopsy proven intramucosal careinom~a, EUS accurately predicts invasiun of the muscularis mucusae or submucosa when disruption of the third layer is noted. However a normal EUS does not exclude the presence of submucosal carcinoma.
VOLUME 45, NO. 4, 1997
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PHOTODYNAMIC THERAPY A L O N E OR WITH THERMAL A B L A T I O N ELIMINATES BARRETT'S ESOPHAGUS. Ber,qein F. Overholt and Masoud Panjehpour, Thompson Cancer Survival Center, Knoxville. TN. PURPOSE. To determine if photodynamic therapy (PDT) alone or in combination with thermal ablation can eliminate Barrett's esophagus. This report presents the results in patients who were being treated with PDT for Barrett's dysplasia or early cancer as part of an ongoing study. METHODS. Seventy-one patients received PDT using sodium porfimer as the photosensitizer. Light (630nm) was delivered endoscopically using a diffuser or by a centering balloon technique. Lugors staining and 4 quadrant biopsies every 2 cm of treated areas were used to identify residual Barrett's mucosa during follow-up endoscopies. All patients were maintained on omeprazole. Follow-up ranged from 6-60 mos. RESULTS. Twenty-three patients had complete ablation of Barrett's mucosa. Eleven of the 23 patients (Barrett's mucosa length range of 2-10 cm; av 4.9 cml were treated with only PDT. Twelve of the 23 patients (Barrett's mucosa length range of 2-12 cm: av 6.9 cm) received PDT followed by contact Nd:YAG laser therapy to residual islands of Barrett's mucosa during follow-up endoscopies. Longer segments of Barrett's mucosa usually required Nd:YAG laser for total ablation although recent work with 5-7 cm centering balloons suggests less need for laser. CONCLUSIONS. PDT alone or in combination with thermal ablation eliminates Barrett's mucosa in selectec~ patients.
ROLE OF ENDOSCOPIC ULTRASOUND IN PATIENTS WITH BARRETT'S ESOPHAGUS AND H I G H GRADE DYSPLASIA. J. Parent. D.S. Levine, R.C. Haggitt, B.J. Reid, M.B Kimmey, Division of Gastroenterologyand Dept. of Pathology, University of Washington, Seattle, WA The detection of early malignancy in BarretX's esophagus remains a cbnlleagmg problem. The omtribution of endoscopic ultrasound (EUS) to the efficacy of endoscopic biopsy surveillance has not been clearly established. AIM: To determine if EUS detects occult adenocareinomas m patients found to have high grade dysplasia in endoscopic surveillance protocols. METHODS: 27 patients (4 females) enrolled in a university-based surveillance program for Barrett's esophagus and found to have high grade dysplasia un biopsy underweat 34 EUS exams. Endoscopic surveillance was performed at 3-6 month intervals with four quadrant biopsms every 1 cul throughout the length of the Barrett's esophagus. Additional biopsies were taken from visible nodules or ulcers. All patients were followed for at least 12 months or until they had smgery. The mean duration of high grade dysplasia was 15.5 months. The metal length of the Barrett's esophagus was 6.6 cm. Endoscopic findings included nodules (11), ulcers (3) and no mucosal lesions (20). EUS was performed using a radial scanning echo endoscope (Olympus GFM-3 or OF-UM20) in all patients. 13 patients were also examined using a 20 MHz linear or radial miniprobe. RESULTS: No abnormalities of the esophageal wall were seen in 27/34 EUS exams. 7 had focal thickening invelving only the mucosa (no disruption of layer 3); 6 of these had a lesion smm on endoscopy (4 nodules & 2 ulcers) and 1 had a normal endoscopy. Benign appearing lymph nodes were identified in 8 EUS exams. When water could be maimained in the lumen, all patiants examined with the miniprobe had thickening or irregularity of layer 2 without disruption of layer 3. Six patients had an esophagectomy within 2 months of the EUS exam and had only dysplasia on pathology. All other patiems remained under endoscopic surveillance; 8 of these underwem surgery 4 to 23 months after EUS, following the development of biopsy proven carcinoma. The 13 remaining patients have been followed for a mean of 27 months (range 15 to 65 months) with exmtinued dysplasia. Based cu these results the specificity of EUS for excluding the presence of carcinoma is 100% with a 95% confidence interval of 89% to 100%. CONCLUSION: EUS does not detect adenocarcinomas in patiants found to have high grade dysplasia on a comprehensive eadeacopic biopsy surveillance protocol for Barrett's esophagus. Sunographic abnormalities are seen primarily in patients with endoscopically visible lesions.
AB76
G A S T R O I N T E S T I N A L ENDOSCOPY
ACCURACY OF ENDOSCOPIC ULTRASOUND STAGING IN PATIENTS WITH BARRETT'S ESOPHAGUS AND INTRAMUCOSAL CARCINOMA. J. Parent, D.S. Levine, R.C. Hagght, D.E. Wood, B.J. Reid, MB. Kimmey, Division of Gastroemerolcgy, Depts of Pathology and Surgery, University of Washington, Seattle, WA The accuracy of endoscopic ultrasound (EUS) staging in patiems with Barrett's esophagus who are found to have intramucoeal carcinoma on endoscopy and biopsy has not been established. MM: To determine the accuracy of EUS staging in patients with Barrett's esophagus and biopsy provan lmramucusal carcinoma by comparing EUS findings m surgical pathology. METHODS: 30 patiants (3 females) with known Burrett's esophagus, found to have intramucosal carcinonm on biopsy, underwent EUS using a radial scanning echo endoscope (Olympus GFM-3 or GF-UM20). 10 patients were also examined using a 20 MI-h linear or radial miniprobe. All patients underwent esophagectomy within one month of the EUS exam. RESULTS: Endoscopic findings included nodules (19), ulcers (3) and no mucosal lesions (8) No abnormalities of the esophageal wall were seen in 16/30 radial EUS exun~, 7 had focal thickening involving only the mucosa (no disruption of layer 3), 7 had thickening of the mucoea and dismpticu of layer 3 suggesting invasion of the muscularis mucosae (m.m.) or of the submucosa. Benlgu appearing lymph nodes were identified in 10 EUS exams. EUS findings Surgical Patholoev normal thickened layer 2 disruption of layer 3 high grade dysplasia 9 3 0 intramucosal cercmoma 4 2 1 m.m. invasion 1 1 2 submucesal invasion 2 1 4 The sensitivity and specificity of EUS in the detection of musculatis mucusae or subraueosal invasion were 55% and 95% respectively. EUS and pathology did not reveal muscularis propria invasion or malignant lymph nodes in any patiem. All 10 exams with the miniprobe showed thickening or irregularity of layer 2 and 4 showed disruption of layer 3 with pathological confirmation of submucosal invasiun in 3/4 CONCLUSION: In patients with Barrett's esophagus and biopsy proven intramucosal careinom~a, EUS accurately predicts invasiun of the muscularis mucusae or submucosa when disruption of the third layer is noted. However a normal EUS does not exclude the presence of submucosal carcinoma.
VOLUME 45, NO. 4, 1997