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7051 Esophageal stent placement without flouroscopy.
7048 RELIEF OF DYSPHAGIA WITH SELF EXPANDING METAL STENTS IS FAR FROM PERFECT. Laurence B. Lovat, Nicoletta Mathou, Sally M. Thorpe, David Gertner, Ian R. Sargeant, Marc C. Winslet, Stephen G. Bown, National Med Laser Ctr, RFUCSM, UCL, London, United Kingdom; Basildon & Thurrock Hospitals NHS Trust, Basildon, United Kingdom; The Lister Hosp, Stevenage, United Kingdom; Dept of Surg, RFUCSM, UCL, London, United Kingdom. Background: Most people with oesophageal cancer present with advanced disease and palliation of dysphagia is the main aim of therapy. Self expanding metal stents (SEMS) have become the standard treatment but patient outcome is not well documented, particularly in routine practice. This is a retrospective analysis of patients treated in 2 district general hospitals and 2 teaching hospitals. Patients and Methods: Hospital notes were reviewed on 75 consecutive patients in whom a SEMS was inserted between January 1996 and May 1997. Site of tumour was: 38 adenocarcinoma of distal oesophagus or cardia; 21 squamous cell carcinoma of the mid or upper body; 5 bronchogenic carcinoma with oesophageal involvement; in 11 the site was not noted. 5 had broncho-oesophageal fistulae and 1 an iatrogenic perforation following tumour dilatation. Results: 88 stents (44 covered) were placed in 75 patients (mean age 70, range 37-92). Stenting was primary therapy for most patients. 4/5 (80%) fistulae were adequately closed. Mean survival for all patients after stent insertion was 67 days (range 5-259). Most were only able to tolerate fluids before stent insertion. In the 42 patients for whom adequate records were kept, only slight improvement of dysphagia was achieved after stent insertion, and most tolerated only pureed food. In 9 of these patients, no improvement was seen in severity of dysphagia, and in 1 other, stenting made dysphagia worse. Severe pain occurred after stent insertion in at least 24 patients (32%) and was intractable in 7 (9%). 4 patients (5%) died within 10 days of stent insertion (2 aspiration pneumonia, 1 stridor, 1 haemorrhage). 16 patients (21%) developed late stent related morbidity. Tumour overgrowth or ingrowth was treated with an overlapping stent in 8 patients (1 required a total of 4 stents); tumour ingrowth was treated with laser in 1 patient; 1 patient died from massive haematemesis at 5 months. This patient had previously undergone radiotherapy. 2 covered metal stents migrated into the stomach whereas this was not seen with uncovered stents. A total of 45 extra endoscopies were performed after stent insertion. Conclusions:In routine practice, SEMS improve dysphagia less well than in trials from specialist centres. Pain is common and can be intractable. Early stent related morbidity is very common and late morbidity occurs in 21%. Furthermore, early mortality after stent insertion is significant and relief of dysphagia appears to be no better than that achieved with silicone rubber tubes. 7049 ENDOSCOPIC PLACEMENT OF ESOPHAGEAL EXPANDABLE METAL STENTS WITHOUT FLUOROSCOPIC GUIDANCE. Bernardino N. Ribeiro, Dario Gomes, Claudia Sequeira, Pedro Amaro, Fernanda Macoas, Sandra Saraiva, Amadeu Cr Nunes, Cilenia Baldaia, Clotilde Lerias, Hermano Gouveia, Maximino C. Leitao, Diniz Freitas, Dept of Gastroenterology, Coimbra Univ Hosp, Coimbra, Portugal; Dept of Gastroenterology Coimbra Univ Hosp, Coimbra, Portugal. The insertion of expandable metal stents (EMS) is a fundamental palliative treatment for esophageal malignant neoplasia. Endoscopic placement of stents is usually performed under fluoroscopic guidance. Aims: Evaluation of feasability, efficacy and safety of the endoscopic insertion of EMS in esophageal malignant neoplasia without fluoroscopic guidance. Patients and Methods: Retrospective study of 60 patients (pts) with nonresectable esophageal cancer in whom 72 EMS were placed. The EMS used were distal release Ultraflex™ (Microvasive®, Boston Scientific Corporation), 7-15 cm long and 18 mm in diameter (22 covered stents). 91% of the patients were previously submitted to dilation and/or Nd:YAG laser. The procedures were done under sedation with midazolam and EMS were placed under endoscopic control with no fluoroscopic guidance. Severity of dysphagia was graded in a 0 to 4 score according to the consistency of food causing symptoms: 0 no dysphagia; 1 solid food; 2 semi-solid food; 3 liquid food; 4 total dysphagia. Results: 49 men and 11 women. Mean age 65±11 years. The indications for EMS insertion were dysphagia (78%) and esophagorespiratory fistulas (22%). Mean stricture length: 7.0±1.9 cm. The neoplasia were located in the upper esophagus in 23%, in the middle in 47% and in the lower in 30%. A significant improvement in dysphagia after stent placement was observed (mean pre-treatment score: 3.1±0.7; mean score after stenting: 1.5±0.5 - p<0.0001). Successful fistula closure was achieved in all cases. The indications for the insertion of more than one stent were: esophagorespiratory fistulas - 7; tumor ingrowth or overgrowth - 4; partial migration - 1. Early complications: incomplete stent expansion - 6; acute tracheal obstruction - 2; pneumonia - 1; mediastinal abcess - 1. Late complications: tumor ingrowth or overgrowth - 14; fistulas - 5; partial migration - 1. Procedure related mortality: none. Mean survival after stenting: 5.5+4.9 months. Conclusions: Endoscopic EMS placement in
AB254
GASTROINTESTINAL ENDOSCOPY
esophageal malignant neoplasia performed without flouroscopic control presented high efficacy with low complication rates. This approach has the advantage of lowering cost and duration of the procedure and avoids exposing pts and staff to radiation 7050 THE NATURAL HISTORY OF BARRETT’S ESOPHAGUS (BE) IN ORTHOTOPIC LIVER TRANSPLANT (OLT) RECIPIENTS. M. L. Rosenblatt, F. Dodson, J. Fung, J. Rakela, H. Vargas, Dept OF MEDICINE, UPMC-SHADYSIDE, Pgh, PA; Starzl Transplant Institute, Pgh, PA; Dept OF TRANSPLANT MEDICINE, Univ OF Pittsburgh, Pgh, PA; Dept OF HEPATOLOGY AND TRANSPLANT MEDICINE, UPMC, Pgh, PA. INTRODUCTION: Current data on the development of malignancies after OLT are limited. Overall, the risk of de novo malignancy after transplantation appears to be increased by the use of immunosuppressive therapy. Cancer incidence in patients who undergo OLT is 0.8%, and up to 4% in children (Transpl Proc 1993;25:1397-9). In the majority of patients with BE there is a clear history of gastrointestinal reflux. Up to 15% of patients will have no complaints. Unrecognized, the estimates of the malignant risk of Barrett’s metaplasia is on the order of 1 case per 150-200 patient years of follow up. Recently, the association between BE and chemotherapy has been raised (Digest Dis Sci 1993;38:351-3). We undertook our study to provide an understanding of the natural history of OLT recipients with known BE and the development of esophageal adenocarcinoma. METHODS: Between 1991 and 1998, a total of 1620 patients underwent OLT at our institution. A computerized data base search was performed to identify patients that underwent OLT and carried a diagnosis of BE. In many patients, coagulopathy and varices prevented biopsies. BE was defined by endoscopic appearance or by histology. RESULTS: 10 patients were determined to have BE (9 males, 1 female). Mean age of 52 years. 2 patients have BE by endoscopic criteria alone. 2 biopsy proven BE patients developed metastatic adenocarcinoma 3 and 9 years after OLT. 7/10 had symptomatic reflux. All patients were on combinations of prograf, FK 506, prednisone or cyclosporine. 7 patients were on chronic acid suppression with either H2RA or PPI. DISCUSSION: Patients with BE who undergo OLT on immunosupressive therapy, may be at a higher risk for the development of esophageal adenocarcinoma. These tumors may appear early during the post-transplantation period, have a rapid course with extragastrointestinal metastases, and, probably, a grave prognosis. Early and more frequent surveillance is recommended for these patients. 7051 ESOPHAGEAL STENT PLACEMENT WITHOUT FLOUROSCOPY. Russell E. White, Caesar Mungatana, Mark D. Topazian, Tenwek Hosp, Bomet, Kenya; Yale Univ Sch of Medicine, New Haven, CT. Background: Esophageal cancer is common in southwestern Kenya, and palliative treatment options are limited for patients with advanced disease. One obstacle preventing use of esophageal stents in our region is lack of flouroscopy equipment. We developed a method for esophageal stent placement without flouroscopy. Methods: Patients with dysphagia due to unresectable esophageal cancer were offered stent placement. All patients had previously undergone endoscopic dilation of their esophageal tumor to at least 36 French. Expandable stents made of stainless steel wire (Wallstent II, Schneider) or knit from nitinol (Ultraflex, Microvasive) were used. Prior to stent placement an endoscope was passed through the tumor to the stomach, a guidewire was placed in the antrum, and the tumor’s position and length were noted during endoscope withdrawal. A stent was passed over the guidewire and through the tumor, after marking the stent delivery catheter at the base of the stent’s proximal flange with an indelible colored mark. The endoscope was then re-introduced into the proximal esophagus alongside the stent delivery catheter, and the catheter was positioned so that the colored mark was visible at the proximal edge of the tumor. Stent deployment was monitored endoscopically with the endoscope tip positioned proximal to the constrained stent. After stent deployment the endoscope was gently passed into or through the stent. Dysphagia scores were recorded before stent placement and at follow-up clinic visits, on a scale ranging from 4 (unable to swallow saliva) to 0 (no dysphagia). Results: Stent placement was attempted in 24 patients and was successful in all cases. Stainless steel stents were placed in 14 patients and nitinol stents in 10 patients. An endoscope could be passed immediately through the stent to the stomach in 19 patients, and in the remaining 5 patients endoscopic views from the mid-shaft of the stent confirmed adequate placement across the entire tumor. Mean dysphagia score was 3.4 prior to stent placement (n=24) and 0.2 after stent placement (n=13). There were no immediate complications of stent placement. One patient returned 10 weeks after stenting with recurrent dysphagia due to tumor growth over the proximal end of the stent, which was successfully treated with placement of a second stent. An additional patient developed reflux symptoms requiring medication. Conclusion: Expandable esophageal stents can be accurately, safely, and easily placed under direct endoscopic control, without flouroscopy.
VOLUME 51, NO. 4, PART 2, 2000
AB254
GASTROINTESTINAL ENDOSCOPY
esophageal malignant neoplasia performed without flouroscopic control presented high efficacy with low complication rates. This approach has the advantage of lowering cost and duration of the procedure and avoids exposing pts and staff to radiation 7050 THE NATURAL HISTORY OF BARRETT’S ESOPHAGUS (BE) IN ORTHOTOPIC LIVER TRANSPLANT (OLT) RECIPIENTS. M. L. Rosenblatt, F. Dodson, J. Fung, J. Rakela, H. Vargas, Dept OF MEDICINE, UPMC-SHADYSIDE, Pgh, PA; Starzl Transplant Institute, Pgh, PA; Dept OF TRANSPLANT MEDICINE, Univ OF Pittsburgh, Pgh, PA; Dept OF HEPATOLOGY AND TRANSPLANT MEDICINE, UPMC, Pgh, PA. INTRODUCTION: Current data on the development of malignancies after OLT are limited. Overall, the risk of de novo malignancy after transplantation appears to be increased by the use of immunosuppressive therapy. Cancer incidence in patients who undergo OLT is 0.8%, and up to 4% in children (Transpl Proc 1993;25:1397-9). In the majority of patients with BE there is a clear history of gastrointestinal reflux. Up to 15% of patients will have no complaints. Unrecognized, the estimates of the malignant risk of Barrett’s metaplasia is on the order of 1 case per 150-200 patient years of follow up. Recently, the association between BE and chemotherapy has been raised (Digest Dis Sci 1993;38:351-3). We undertook our study to provide an understanding of the natural history of OLT recipients with known BE and the development of esophageal adenocarcinoma. METHODS: Between 1991 and 1998, a total of 1620 patients underwent OLT at our institution. A computerized data base search was performed to identify patients that underwent OLT and carried a diagnosis of BE. In many patients, coagulopathy and varices prevented biopsies. BE was defined by endoscopic appearance or by histology. RESULTS: 10 patients were determined to have BE (9 males, 1 female). Mean age of 52 years. 2 patients have BE by endoscopic criteria alone. 2 biopsy proven BE patients developed metastatic adenocarcinoma 3 and 9 years after OLT. 7/10 had symptomatic reflux. All patients were on combinations of prograf, FK 506, prednisone or cyclosporine. 7 patients were on chronic acid suppression with either H2RA or PPI. DISCUSSION: Patients with BE who undergo OLT on immunosupressive therapy, may be at a higher risk for the development of esophageal adenocarcinoma. These tumors may appear early during the post-transplantation period, have a rapid course with extragastrointestinal metastases, and, probably, a grave prognosis. Early and more frequent surveillance is recommended for these patients. 7051 ESOPHAGEAL STENT PLACEMENT WITHOUT FLOUROSCOPY. Russell E. White, Caesar Mungatana, Mark D. Topazian, Tenwek Hosp, Bomet, Kenya; Yale Univ Sch of Medicine, New Haven, CT. Background: Esophageal cancer is common in southwestern Kenya, and palliative treatment options are limited for patients with advanced disease. One obstacle preventing use of esophageal stents in our region is lack of flouroscopy equipment. We developed a method for esophageal stent placement without flouroscopy. Methods: Patients with dysphagia due to unresectable esophageal cancer were offered stent placement. All patients had previously undergone endoscopic dilation of their esophageal tumor to at least 36 French. Expandable stents made of stainless steel wire (Wallstent II, Schneider) or knit from nitinol (Ultraflex, Microvasive) were used. Prior to stent placement an endoscope was passed through the tumor to the stomach, a guidewire was placed in the antrum, and the tumor’s position and length were noted during endoscope withdrawal. A stent was passed over the guidewire and through the tumor, after marking the stent delivery catheter at the base of the stent’s proximal flange with an indelible colored mark. The endoscope was then re-introduced into the proximal esophagus alongside the stent delivery catheter, and the catheter was positioned so that the colored mark was visible at the proximal edge of the tumor. Stent deployment was monitored endoscopically with the endoscope tip positioned proximal to the constrained stent. After stent deployment the endoscope was gently passed into or through the stent. Dysphagia scores were recorded before stent placement and at follow-up clinic visits, on a scale ranging from 4 (unable to swallow saliva) to 0 (no dysphagia). Results: Stent placement was attempted in 24 patients and was successful in all cases. Stainless steel stents were placed in 14 patients and nitinol stents in 10 patients. An endoscope could be passed immediately through the stent to the stomach in 19 patients, and in the remaining 5 patients endoscopic views from the mid-shaft of the stent confirmed adequate placement across the entire tumor. Mean dysphagia score was 3.4 prior to stent placement (n=24) and 0.2 after stent placement (n=13). There were no immediate complications of stent placement. One patient returned 10 weeks after stenting with recurrent dysphagia due to tumor growth over the proximal end of the stent, which was successfully treated with placement of a second stent. An additional patient developed reflux symptoms requiring medication. Conclusion: Expandable esophageal stents can be accurately, safely, and easily placed under direct endoscopic control, without flouroscopy.
VOLUME 51, NO. 4, PART 2, 2000