Sa1563 The Clinical Utility of Endoscopic Ultrasound Before Ablation in Patients With Barrett's Esophagus and High-Grade Dysplasia or Intramucosal Carcinoma

Sa1563 The Clinical Utility of Endoscopic Ultrasound Before Ablation in Patients With Barrett's Esophagus and High-Grade Dysplasia or Intramucosal Carcinoma

Abstracts rates were similar to RFA for flat dysplasia. Dysplasia, either flat or nodular, eradication was a durable response at a median follow-up o...

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Abstracts

rates were similar to RFA for flat dysplasia. Dysplasia, either flat or nodular, eradication was a durable response at a median follow-up of 26 months.

Sa1563 The Clinical Utility of Endoscopic Ultrasound Before Ablation in Patients With Barrett’s Esophagus and High-Grade Dysplasia or Intramucosal Carcinoma William J. Bulsiewicz1, Albert J. Rogers3, Evan S. Dellon1, Sarina Pasricha2, Ryan D. Madanick1, Ian S. Grimm1, Nicholas J. Shaheen1 1 Division of Digestive Diseases, Center for Esophageal Diseases & Swallowing, University of North Carolina School of Medicine, Chapel Hill, NC; 2Internal Medicine Residency Program, University of North Carolina School of Medicine, Chapel Hill, NC; 3University of North Carolina School of Medicine, Chapel Hill, NC Background: Endoscopic ultrasound (EUS) is often used to stage patients with Barrett’s esophagus (BE) and high-grade dysplasia (HGD) or intramucosal carcinoma (IMC) prior to ablation, since tumor invasion or lymphadenopathy might preclude endoscopic therapy in favor of esophagectomy. The clinical utility of EUS in this role is unclear.AIM: To assess the utility of EUS prior to ablation in BE patients with HGD or IMC. Methods: We performed a retrospective analysis of endoscopy records to identify all BE patients with HGD or IMC, as confirmed by histology, who underwent upper EUS in anticipation of endoscopic ablative therapy at our institution between June 2006 and November 2010. Pertinent data were extracted, including demographics, disease-specific parameters (histology before EUS, time with BE/dysplasia prior to EUS), endoscopic findings (Prague C/M classification, presence of esophagitis or nodule), EUS findings (tumor invasion, submucosal nodule, wall thickening, lymph nodes) and fine needle aspiration results. Contraindications to ablation were defined as tumor invasion beyond the superficial submucosa on EUS, regional lymph node involvement, invasive adenocarcinoma on endoscopic mucosal resection specimen, or distant metastasis. Results: Among 273 patients identified by endoscopy records, 7 did not have BE, 37 did not have an EUS, and 94 had an EUS for an alternative indication. The remaining 135 patients with BE and an EUS for pre-ablation staging were analyzed. Forty four subjects underwent EMR. Ablation was contraindicated in 14 patients (8 with invasion beyond superficial submucosa on EUS, 6 with invasive adenocarcinoma detected by EMR). Ablation contraindications were more likely among those with IMC (78.6% vs. 14.9%, p⬍0.01), mucosal nodularity (100%vs. 34.7%, p⬍0.001), wall thickening on EUS (100% vs. 32.2%, p⬍0.001), and suspicious lymph nodes on EUS (35.7% and 3.3%, p⫽0.001). Stratified by histology and nodularity, ablation was contraindicated in 11/21 with nodular IMC (52%) and 3/35 with nodular HGD (9%). EUS identified invasion beyond the superficial submucosa in 5/21 with nodular IMC (24%) and 3/35 with nodular HGD (9%). EMR upstaged histology in 10/18 with nodular HGD (56%) and 6/10 with nodular IMC (60%), all 6 of which were invasive adenocarcinoma. All 79 patients with non-nodular disease (HGD or IMC) lacked contraindication to ablation. There were no complications attributed to EUS. Conclusions: EUS identified a contraindication to ablation in 9% with nodular HGD and 24% with nodular IMC but did not alter management in patients with non-nodular disease. The diagnostic utility of EUS in such subjects is low.

Sa1564 Reflux Esophagitis (RE) in Patients With Partial Distal and Total Gastrectomy: Case-Control Study Roman Kuvaev1, Sergey V. Kashin1, Igor O. Ivanikov2, Nikolai Akhapkin3 1 Endoscopy, Yaroslavl Regional Cancer Hospital, Yaroslavl, Russian Federation; 2Gastroenterology and Hepatology, Government Hospital, Moscow, Russian Federation; 3Surgery, Yaroslavl Regional Cancer Hospital, Yaroslavl, Russian Federation Background: Distal and total gastrectomy has become a common operation for patients with gastric carcinoma or other benign or malignant conditions involving the stomach. RE is the one of the most frequent complications that might develop in patients after such operations. It represents a challenge for treatment and decrease the quality of life of patients. For working out the patient management it is crucial to identify the extent of the problem. The aim of the study was to analyze the prevalence and severity of RE in patients with distal and total gastrectomy in comparison with unoperated patients. Methods: A retrospective review of 564 patients (mean age 64.6 years, SD⫽10.2) with previous distal (Billroth-II) or total gastrectomy who had undergone endoscopic follow-up between Jan 2005 and Nov 2010 was performed. In all of patients gastric cancer was the indication for surgery. We also reviewed the endoscopic findings in 9,823 (mean age 54.9 years, SD⫽15.8) age- and sex-matched controls who had visited our hospital for routine check-up without gastric surgery. The presence of erosive RE was based on the Los Angeles (LA) Classification.

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Additionally minimal changes of mucosa (such as hyperemia and edema) observed under endoscopic investigation (Olympus GIF H180, GIF 160Z, GIF H260Z) were recorded as a manifestation of non-erosive RE. Results: The prevalence of RE was 8.9% in patients with previous gastric surgery and 4.7% in control group. In particular, RE was found in 22.5% of patients after total gastrectomy and only in 1.9% of patients after distal gastrectomy. Of the 50 patients with RE after total (43 cases) and distal (7 cases) gastrectomy, 4 (8%) had minimal changes, 4 (8%) had LA grade A, 16 (32%) had LA grade B, 17(34%) had LA grade C, 9 (18%) had LA grade D. The prevalence of severe forms of RE (grade C and D) was 52% from total number of patients with RE after gastric surgery. The severity of RE in control group (463 cases) was of different type. Minimal changes were found in 126 cases (27.3%), LA grade A - in 124 cases (24.8%), LA grade B - in 181 cases (39%), LA grade C - in 21 cases (2.4%), LA cases D - in 11 cases (2.4%). In contrast, the prevalence of grade C and D RE was only 6.9% from total number of patients with RE in controls. The results are summarized in the table. Conclusion: These results suggest that risk of RE after gastric surgery increases 1.9-fold in comparison with unoperated patients and total gastrectomy significantly increases the risk of RE 4.8-fold. The prevalence of severe forms of RE (grade C and D) was higher in patients after gastric surgery.

Prevalence of RE

Total patients after gastric surgery (nⴝ564)

Total gastrectomy (nⴝ191)

Distal gastrectomy (nⴝ373)

Unoperated patients (nⴝ9823)

No RE RE (total) Minimal changes Grade A Grade B Grade C Grade D

514 (91.1%) 50 (8.9%) 4 (8%)* 4 (8%)* 16 (32%)* 17 (34%)* 9 (18%)*

148 (77.5%) 43 (22.5%) 2 (4.6%)* 4 (9.2%)* 13 (30.2%)* 16 (37.2%)* 8 (18.6%)*

366 (98.1%) 7 (1.9%) 2 (28.6%)* 0 (0%)* 3 (42.3%)* 1 (14.3%)* 1 (14.3%)*

9360 (95.3%) 463 (4.7%) 126 (27.3%)* 124 (26.8%)* 181 (39%)* 21 (4.5%)* 11 (2.4%)*

% from total number of patients with RE.

Sa1565 Radiofrequency Ablation Achieves Ninety Six Percent Complete Response for Intestinal Metaplasia (CR-IM) in Barrett’s Esophagus: A Single Center Experience Shiva K. Ratuapli1, Michael D. Crowell1, Kevin C. Ruff1, Hack J. Kim2, Virender Sharma2, Rahul Pannala1, Francisco C. Ramirez1, David E. Fleischer1 1 Gastroenterology, Mayo Clinic Arizona, Scottsdale, AZ; 2Arizona Center for Digestive Health, Gilbert, AZ Background: Barrett’s esophagus (BE) increases the risk of esophageal adenocarcinoma. at least 200 fold for pts with IM only and more so with dysplasia. Endoscopic surveillance has traditionally been recommended to prevent this progression in pts with IM and low grade dysplasia (LGD). Surgery or endoscopic therapy (ET) has been suggested for some cases of high grade dysplasia (HGD) and/or intramucosal adenocarcinoma. Radiofrequency ablation (RFA) is frequently used ET, with varied success rates and complication rates, but the effect of RFA on BE is not entirely known. Aim: To derive the CR-IM rate in patients treated with RFA at a single center followed over a seven year period. Methods: Retrospective chart review was done for all patients who had RFA from December 2003 to November 2010. HALO 360 (BARX Medical Inc., Sunnyvale, CA) was used for circumferential RFA, and HALO 90 was used for focal RFA. CRIM is defined as no residual Barrett’s after RFA. Based on the follow up (FU) data, patients were grouped into: a) complete FU b) FU pending c) lost to FU. Complete FU was defined as either endoscopic and pathology evidence of CR-IM seen, or referred to surgery. FU pending was defined as either last biopsy showed non dysplastic BE and surveillance was chosen or biopsy showed dysplastic BE, with further RFA s scheduled. Demographic and endoscopic data were analyzed using JMP (v8, Cary NC). Data are presented as mean ⫾ SD and proportions. Results: A total of 174 patients underwent RFA, of which 62 patients have FU pending or have been lost to FU. 112 patients with complete FU information are reported here. The mean age was 68 ⫾ 12 yrs, and 98(88 %) were male. The mean BMI was 29 ⫾ 5, and 111(99%) were Caucasian. 93(84%) patients had gastroesophageal reflux disease, and 18 (16 %) had Nissen fundoplication. The mean BE length was 4.6 ⫾ 3.4 cm, and 101(90%) had hiatal hernia. The mean duration of BE diagnosis prior to RFA was 43 ⫾ 54 months. Initial pathology, prior to RFA were: non-dysplastic - 30(27 %), indefinite for dysplasia - 13(12%), LGD - 25(22%), HGD - 39(35%), adenocarcinoma - 5(4%). Of the 112 patients, CR - IM was achieved in 108(96%), and the number of RFAs needed/ patient were 2 ⫾ 1.08 (Circumferential 0.92 ⫾ 0.82, focal 1.07⫾ 0.77). Eleven patients had complications: 6 prolonged chest pain, 4 strictures and 1 bleeding. Mean duration of FU after RFA was 28 ⫾ 18 months, including 7 patients who continue to have CR-IM at 5-year follow up. Conclusion: Our experience shows that RFA is safe and effective and achieves 96% CR-IM in the combined group of dysplastic and non-dysplastic BE patients. Based on our experience and the results from a few other multicenter trials, RFA should strongly be considered as initial treatment for Barrett’s esophagus. Follow up to define durability of CR-IM is appropriate.

Volume 73, No. 4S : 2011

GASTROINTESTINAL ENDOSCOPY

AB209