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⁎⁎3721 ARTIFICIAL NEURAL NETWORK - A TOOL FOR PREDICTING NEED FOR ENDOSCOPIC TREATMENT IN PATIENTS WITH NONVARICEAL UPPER GASTROINTESTINAL BLEEDING.
**3721 ARTIFICIAL NEURAL NETWORK - A TOOL FOR PREDICTING NEED FOR ENDOSCOPIC TREATMENT IN PATIENTS WITH NONVARICEAL UPPER GASTROINTESTINAL BLEEDING. A. Das, R. C. Wong, J. A. Gonet, D. Haghighi, A. Chak, G. S. Cooper, M. V. Sivak Jr., Univ Hospitals of Cleveland, Cleveland, OH. A reliable tool to predict endoscopic stigma of recent hemorrhage (SRH) and need for ET based on clinical information available at initial evaluation of patients with UGIB would be useful for triaging high-risk patients for urgent endoscopy. Aim: To evaluate role of an ANN based predictive model in predicting SRH and need for ET in patients with UGIB. Methods: Clinical data on all patients admitted with UGIB during a 15 month period starting January 1998 were prospectively collected. A multi-layered perceptron ANN was constructed using clinical variables available at initial evaluation. The ANN was trained by back-propagation using data from initial 9 months (Group I) and then validated using data from the last 6 months (Group II). The ANN was blinded to the endoscopic finding of patients from Group II. For comparison, a stepwise logistic regression model was constructed using the available clinical input variables. Also, two validated scoring systems viz. Baylor pre-endoscopic score (Am J Gastroenterol 1993) and Decision rule by Corley et al ( Am J Gastroenterol 1998) were used to classify patients into high and low risk groups. Presence of SRH and need for ET were the two outcome parameters used to compare the different predictive models. Results: 327 patients (Mean age 66.2 years, 169 males) were available for analysis. The clinical features were similar in Group I (n = 208) and Group II (n = 119). SRH was present in 110 (33.6%) patients and ET was performed in 105 (32.1%). ANN performed better than other models (Table). Area under the receiver operating curve for ANN were 0.89 and 0.93 for presence of SRH and ET, respectively. Conclusion: ANN performed extremely well in predicting presence of SRH and need for ET from information available at initial presentation. ANN may be a useful tool in triaging patients with UGIB for urgent endoscopy.
Predictive Method ANN
Logistic Regression
Baylor Pre-endoscopic Score Decision Rule by Corley et al
Endoscopic SRH
Endoscopic
92% sens1, 84% spec2; DP3 3.1 58% Sens, 79% Spec; DP <1
94% Sens, 87% spec; DP 2.6 47% Sens, 86% Spec; DP <1
48% Sens, 38% Spec; DP <1 14% Sens, 96% Spec; DP <1
43% Sens, 96% Spec; DP 1.7 15% Sens, 64% Spec; DP <1
Therapy
1Sensitivity, 2Specificity, 3Discriminant Power
**3722 ENDOSCOPIC ULTRASOUND PREDICTORS OF LONG TERM SURVIVAL IN ESOPHAGEAL CARCINOMA. P. R. Pfau, G. G. Ginsberg, R. J. Lew, C. M. Brensinger, Ml Kochman, Univ of Pennsylvania, Philadelphia, PA. Endoscopic ultrasound (EUS) has been proven to be the most accurate staging modality for esophageal cancer (EsoCa). However, the ability of EUS to predict outcomes or prognosis is unclear. We prospectively followed patients who had EUS for EsoCa staging to determine if EUS can predict survival in EsoCa. Methods: 204 consecutive patients undergoing EUS for EsoCa staging were studied over a 66 month (mo.) period. Survival data was determined in 196 patients. Median survival was calculated for each T-stage and N-stage as determined by EUS. Kaplan Meier survival curves were generated for each stage and Cox regression was used to test for statistically significant differences in survival adjusting for age, sex, and histology (adeno CA vs. squamous cell CA). The differences in survival in T stage and N stage were adjusted for N stage and T stage respectively. Results: The incidence of each T and N stage was Tis (7), T1 (24), T2 (47),
AB136
GASTROINTESTINAL ENDOSCOPY
T3 (93), T4(28), Tx (5) and N0 (53), N1 (145), Nx (6). Median follow-up after EUS exam was 35.4 mos. ranging from 12 to 66 mos. Median survival in mos. for each stage was Tis (26.7), T1 (21.6), T2 (19.5), T3 (15.6), T4 (6.5) and N0 (25.0), N1 (13.5). Overall there was a significant difference in the ability of EUS determined T stage to predict survival (p=0.001), with patients having higher EUS T stages succumbing sooner. This difference remained significant after adjusting for age, sex, and histology (P=.035). Patients with local disease (Tis, T1, T2) determined by EUS live significantly longer when compared with patients with advanced disease (T3, T4) (HR=2.0, 95%CI 1.34-2.95). Patients with EUS N stage 0 had significantly longer survival than patients with EUS N stage 1 [25.0 mos. vs. 13.5 mos.] (p<0.001, HR=3.9, 95% CI 2.2-6.8), which was unchanged when adjusted for age, sex, and histology (p<0.001). Differences in survival based on T stage adjusted for N stage showed T stage not to be a predictor of survival (p=.417). When differences in survival based on N stage were adjusted for T stage N stage remained a significant predictor of survival (p=.0005). Conclusions: (1) EUS can predict long-term survival in EsoCa based on initial T staging and the presence of lymphadenopathy on pre-treatment EUS. (2) Esophageal cancer patients with advanced disease as determined by EUS will have significantly shorter survival. (3) Patient’s age, sex, and histology of the tumor does not significantly alter the ability of EUS T and N stage to predict survival. (4) The presence of lymphadenopathy at EUS is the most important predictor of survival. (5) EUS should be performed in all EsoCa patients to not only stage patients prior to therapy but also as a prognostic tool.
**3723 QUALITY OF LIFE AND SYMPTOMATIC IMPROVEMENT IN PATIENTS WITH ACHALASIA: A PROSPECTIVE STUDY. Kristen Robson, Mohammed S. Zaman, Jonathan Critchlow, Ciaran P. Kelly, Stanley Rosenberg, Ian Gralnek, Tony Lembo, Beth Israel Deaconess Med Ctr, Boston, MA; UCLA Med Ctr, Los Angeles, CA. Objective: Treatment for achalasia includes surgical myotomy, pneumatic dilation and injection of botulinum toxin. Success rates range from 32% to 98% and are mostly based on symptomatic improvement. The aim of this study was to evaluate prospectively the symptomatic response and health related quality of life (HRQOL) in patients treated for achalasia. Methods: Eighteen patients with achalasia who presented for treatment were enrolled in the study. Patients completed the Health Status Questionnaire 2.0 (HSQ), a standardized measure of health status, and a symptom questionnaire (SQ) prior to treatment and after an average of 5.2 months follow-up. The SQ (visual analogue scale) measured the severity of dysphagia, regurgitation, chest pain and pressure, cough and heartburn. Symptom scores pre- and post-treatment were compared for all patients. HSQ was analyzed using the Microtest Q Assessment SystemTM. Eight scales describing the components of health status were compared for all patients pre- and post-treatment. Subgroup analyses were done comparing endoscopic versus surgical treatment. Results: To date, 18 patients have completed the follow-up questionnaire. One patient did not complete the HSQ and was excluded from the HSQ analysis. Six patients underwent myotomy, 9 patients had botulinum toxin injection and 3 patients had pneumatic dilation. The average patient age was 56.3 ±17.5 years (range 29-92 years). Ten patients were female (56%). Improvement was noted in patients post-treatment for the following symptoms: dysphagia (mean scores 5.6 pre- and 1.9 post-treatment; p<0.002, t test) and chest pain (mean scores 3.5 pre- and 2.3 post-treatment; p<0.05, t test). Improvement in HRQOL for the social functioning scale was present post-treatment (mean scores 65.4 pre- and 86.8 post-treatment; p<0.01, t test). No significant differences were found in the subgroup analyses for either symptom scores or HRQOL (p<0.05). Discussion: Patients who received endoscopic and surgical treatment for achalasia had significant improvement in dysphagia and chest pain. Improvement in HRQOL on the scale of social functioning was also present. This may be explained by the fact that after treatment patients are able to participate in meals without significant dysphagia or chest pain. Conclusion: This preliminary data shows that treatment for achalasia results in improvement in dysphagia, chest pain and social functioning. Long term study is needed to determine if these improvements are transient or remain present over time.
VOLUME 51, NO. 4, PART 2, 2000
Predictive Method ANN
Logistic Regression
Baylor Pre-endoscopic Score Decision Rule by Corley et al
Endoscopic SRH
Endoscopic
92% sens1, 84% spec2; DP3 3.1 58% Sens, 79% Spec; DP <1
94% Sens, 87% spec; DP 2.6 47% Sens, 86% Spec; DP <1
48% Sens, 38% Spec; DP <1 14% Sens, 96% Spec; DP <1
43% Sens, 96% Spec; DP 1.7 15% Sens, 64% Spec; DP <1
Therapy
1Sensitivity, 2Specificity, 3Discriminant Power
**3722 ENDOSCOPIC ULTRASOUND PREDICTORS OF LONG TERM SURVIVAL IN ESOPHAGEAL CARCINOMA. P. R. Pfau, G. G. Ginsberg, R. J. Lew, C. M. Brensinger, Ml Kochman, Univ of Pennsylvania, Philadelphia, PA. Endoscopic ultrasound (EUS) has been proven to be the most accurate staging modality for esophageal cancer (EsoCa). However, the ability of EUS to predict outcomes or prognosis is unclear. We prospectively followed patients who had EUS for EsoCa staging to determine if EUS can predict survival in EsoCa. Methods: 204 consecutive patients undergoing EUS for EsoCa staging were studied over a 66 month (mo.) period. Survival data was determined in 196 patients. Median survival was calculated for each T-stage and N-stage as determined by EUS. Kaplan Meier survival curves were generated for each stage and Cox regression was used to test for statistically significant differences in survival adjusting for age, sex, and histology (adeno CA vs. squamous cell CA). The differences in survival in T stage and N stage were adjusted for N stage and T stage respectively. Results: The incidence of each T and N stage was Tis (7), T1 (24), T2 (47),
AB136
GASTROINTESTINAL ENDOSCOPY
T3 (93), T4(28), Tx (5) and N0 (53), N1 (145), Nx (6). Median follow-up after EUS exam was 35.4 mos. ranging from 12 to 66 mos. Median survival in mos. for each stage was Tis (26.7), T1 (21.6), T2 (19.5), T3 (15.6), T4 (6.5) and N0 (25.0), N1 (13.5). Overall there was a significant difference in the ability of EUS determined T stage to predict survival (p=0.001), with patients having higher EUS T stages succumbing sooner. This difference remained significant after adjusting for age, sex, and histology (P=.035). Patients with local disease (Tis, T1, T2) determined by EUS live significantly longer when compared with patients with advanced disease (T3, T4) (HR=2.0, 95%CI 1.34-2.95). Patients with EUS N stage 0 had significantly longer survival than patients with EUS N stage 1 [25.0 mos. vs. 13.5 mos.] (p<0.001, HR=3.9, 95% CI 2.2-6.8), which was unchanged when adjusted for age, sex, and histology (p<0.001). Differences in survival based on T stage adjusted for N stage showed T stage not to be a predictor of survival (p=.417). When differences in survival based on N stage were adjusted for T stage N stage remained a significant predictor of survival (p=.0005). Conclusions: (1) EUS can predict long-term survival in EsoCa based on initial T staging and the presence of lymphadenopathy on pre-treatment EUS. (2) Esophageal cancer patients with advanced disease as determined by EUS will have significantly shorter survival. (3) Patient’s age, sex, and histology of the tumor does not significantly alter the ability of EUS T and N stage to predict survival. (4) The presence of lymphadenopathy at EUS is the most important predictor of survival. (5) EUS should be performed in all EsoCa patients to not only stage patients prior to therapy but also as a prognostic tool.
**3723 QUALITY OF LIFE AND SYMPTOMATIC IMPROVEMENT IN PATIENTS WITH ACHALASIA: A PROSPECTIVE STUDY. Kristen Robson, Mohammed S. Zaman, Jonathan Critchlow, Ciaran P. Kelly, Stanley Rosenberg, Ian Gralnek, Tony Lembo, Beth Israel Deaconess Med Ctr, Boston, MA; UCLA Med Ctr, Los Angeles, CA. Objective: Treatment for achalasia includes surgical myotomy, pneumatic dilation and injection of botulinum toxin. Success rates range from 32% to 98% and are mostly based on symptomatic improvement. The aim of this study was to evaluate prospectively the symptomatic response and health related quality of life (HRQOL) in patients treated for achalasia. Methods: Eighteen patients with achalasia who presented for treatment were enrolled in the study. Patients completed the Health Status Questionnaire 2.0 (HSQ), a standardized measure of health status, and a symptom questionnaire (SQ) prior to treatment and after an average of 5.2 months follow-up. The SQ (visual analogue scale) measured the severity of dysphagia, regurgitation, chest pain and pressure, cough and heartburn. Symptom scores pre- and post-treatment were compared for all patients. HSQ was analyzed using the Microtest Q Assessment SystemTM. Eight scales describing the components of health status were compared for all patients pre- and post-treatment. Subgroup analyses were done comparing endoscopic versus surgical treatment. Results: To date, 18 patients have completed the follow-up questionnaire. One patient did not complete the HSQ and was excluded from the HSQ analysis. Six patients underwent myotomy, 9 patients had botulinum toxin injection and 3 patients had pneumatic dilation. The average patient age was 56.3 ±17.5 years (range 29-92 years). Ten patients were female (56%). Improvement was noted in patients post-treatment for the following symptoms: dysphagia (mean scores 5.6 pre- and 1.9 post-treatment; p<0.002, t test) and chest pain (mean scores 3.5 pre- and 2.3 post-treatment; p<0.05, t test). Improvement in HRQOL for the social functioning scale was present post-treatment (mean scores 65.4 pre- and 86.8 post-treatment; p<0.01, t test). No significant differences were found in the subgroup analyses for either symptom scores or HRQOL (p<0.05). Discussion: Patients who received endoscopic and surgical treatment for achalasia had significant improvement in dysphagia and chest pain. Improvement in HRQOL on the scale of social functioning was also present. This may be explained by the fact that after treatment patients are able to participate in meals without significant dysphagia or chest pain. Conclusion: This preliminary data shows that treatment for achalasia results in improvement in dysphagia, chest pain and social functioning. Long term study is needed to determine if these improvements are transient or remain present over time.
VOLUME 51, NO. 4, PART 2, 2000