- Email: [email protected]
Buried Glandular Mucosa After Radiofrequency Ablation of Dysplasia in Barrett's Esophagus
Abstracts
0-IIb esophageal carcinoma underwent ESD. Two cultured autologous oral mucosal epithelial cell sheets were transplanted to the 2/3 circumferential ulceration. Four weeks after ESD, complete healing was observed with no sign of constriction. Conclusions: Based on these findings, it is concluded that this treatment promotes wound healing and prevent inflammation and constriction after EMR/ESD, thereby improves post-operative quality of life of patients.
M1484 Buried Glandular Mucosa After Radiofrequency Ablation of Dysplasia in Barrett’s Esophagus Kenneth E. Fasanella, Alyssa M. Krasinskas, Jon M. Davison, Asif Khalid, Kevin McGrath Background: Radiofrequency ablation (RFA) is an accepted modality for endoscopic treatment of dysplastic Barrett’s esophagus. Neosquamous mucosal ingrowth overlying persistent intestinal metaplasia, known as buried glandular mucosa, or ‘‘buried Barrett’s,’’ has been observed after other endoscopic ablative techniques. However, there have been no reports of this finding in surveillance biopsies after RFA. Methods: We identified all patients treated at our center for Barrett’s esophagus using the HALO ablation system. Patients were excluded if they had been treated with other ablation modalities, or if no follow-up biopsies were available. Seattle protocol biopsies were obtained of the length of treated esophagus between 6 and 12 weeks after the most recent RFA. Biopsies were interpreted by expert pathologists at our institution. Buried glandular mucosa was defined as specialized columnar epithelium beneath a layer of squamous epithelium with no communication with the surface. Follow-up was defined as the time from first RFA treatment to most recent biopsy. All patients were treated with twice daily PPI for at least 6 weeks after RFA. Results: A total of 41 patients were identified and 27 were included in the study. Fourteen patients were excluded due to a history of treatment with other ablation modalities (8) and lack of follow-up pathology (6). The median age was 61 years (interquartile range (IQR); 55, 74) and 70% were male. The median Barrett’s segment length was 2 cm (IQR 0.5, 6). The cohort included 3 patients with non-dysplastic Barrett’s, 5 with low-grade dysplasia (LGD), and 19 with high-grade dysplasia (HGD), 6 of whom also had intramucosal adenocarcinoma. Thirteen of these had undergone EMR prior to RFA. Three underwent circumferential ablation only, 18 underwent focal ablation only, and 6 underwent step-wise circumferential and focal RFA. The median number of treatment sessions was 2 (IQR 1, 2) and median follow-up was 6 months (IQR 5, 11). Buried glandular mucosa was reported in 4 patients (14.8%); 3 of these patients initially had HGD and one had LGD. RFA was repeated in all 4 patients. In one, buried glandular mucosa was not observed on Seattle protocol biopsies on three subsequent occasions. In the others, repeat surveillance biopsies have not yet been obtained. Conclusions: Buried glandular mucosa can be seen in surveillance biopsies after treatment with RFA for dysplastic Barrett’s esophagus. As RFA is well tolerated, patients with this finding can be retreated. The clinical importance of this entity remains to be determined and further follow-up will be necessary to determine clearance rates of these changes.
M1485 Treatment of Malignant Gastro-Duodenal Obstruction Using a Nitinol Self Expanding Metal Stent - An International Prospective Multicenter Experience Guido Costamagna, Andrea Tringali, Julius Spicak, John M. Shaw, Massimiliano Mutignani, Andre Roy, Erik Johnsson, Eduardo Guimara˜es H. De Moura, Spencer Cheng, Thierry Ponchon, Max Bittinger, ´ Laugier, Juha Saarnio, Helmut Messmann, Horst Neuhaus, Rene Francisco Igea Arisqueta Objectives: To document technical and clinical success, and complications associated with use of the WallFlexÔ Duodenal Stent (Boston Scientific Corp, Natick, USA) for the palliative management of malignant gastro-duodenal obstruction per standard of practice in a large international multi-centric experience. Stent performance is documented in the largest prospective series conducted to date. Methods: A web-based registry is conducted at 12 endoscopy centers in 10 countries. Follow-up to 9 months is ongoing. An interim analysis is presented. Results: 202 patients (49% male, mean age 70) were enrolled. Most common causes of the stricture were pancreatic cancer (51%), gastric cancer (18%), and duodenal cancer (10%). Stent length was 9 cm (53%), 6 cm (38%), or 12 cm (9%). Technical success was achieved in 96% (193/202). Gastric Outlet Obstruction (GOO) improved from 14% of patients at Baseline tolerating soft solids or low
AB254 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
residue/normal diet to 84% at 15 days, 86% at 30 days, 81% at 90 days, and 79% at 180 days. At 90 days post stent placement compared to Baseline, symptoms of postprandial epigastric tenderness, nausea and vomiting improved in 50%, 55% and 69% of patients respectively and did not worsen in 95% for all three symptoms. The most significant complications to date include stent migration (3%), stent fracture (0.5%), perforation (0.5%), cholangitis (1%), pancreatitis (0.5%), and GOO due to tumor ingrowth (10%), tumor overgrowth (3%) or food impaction (2%). Retreatment occurred in 19 patients (13%); 16/19 received another self-expanding metal stent. To date 59% (119/202) patients died, none due to stent or stenting related complications. Conclusion: Preliminary results from this International Registry related to the WallFlexÔ Duodenal Stent, confirm the effectiveness of the endoscopic treatment of GOO with SEMS with acceptable complication profile. Endoscopic re-treatment of malfunctioning (ingrowth/overgrowth) or migrated SEMS is possible.
M1486 Size Matters - SEMS in Pancreatic Necrosis Georg F. Kaehler, Sebastian Belle, Peter H. Collet Background: After H. Seifert proposed endoscopic transgastric debridement many endoscopists carried out pancreatic necrosectomies. Mostly complete cleansing is not achievable in the first session. More than one flap Stent will be changed every session and sometimes the patients need additional rinsing tubes. Methods: Herein we describe the use of a special metallic stent which was designed to keep the pancreaticogastrostomy open in 3 cases. It is a self expanding metal mesh stent with 50 mm length and 20-25 mm diameter. The indication for necrosectomy was made due to infected necrosis in all cases. The decision to use a SEMS was insufficient therapy with flap stents in two cases and visible solid character of the necrosis in the us in the remaining. After establishing of a cystogastrostomy in two cases and one cystoduodenostomy we dilated the cystoenterostomy with a balloon up to 20 mm. Visible and mobile necrotic material was extracted gently with a Dormia basket. Treatment was defined as intervall from implantation of the SEMS until explantation as shown in the table. If no more necrosis was visible the SEMS was removed. Results: In all cases the pancreatic necrosis could be resolved. In a treatment period of 7-8 d with 2-3 endoscopic procedures we achieved clinical success in all cases without major complications. Discussion: In our knowledge this is the first report about the use of metallic stents for transgastric necrosectomy of the pancreas. We conclude from this observation that SEMS promosing new tool. It seems to us that SEMS accelerate healing and are more convenient to the patient.
onset to Age therapy Indication
Treatment period complication
65 73
59 d 144 d
infected necrosis infected necrosis
7d 8d
42
791
infected necrosis/ pain
7d
Endoscopic sessions
none transitory gastric outlet obstruction none
3 3
2
M1487 Biodegradable Stents in Refractory Benign Oesophageal Strictures - First Report of 4 Patients from UK Anjan Dhar, Joanne H. Topping, Emma Johns, Denise O’Neill Introduction: Benign peptic strictures can sometimes be refractory to endoscopic dilatations, with patients requiring frequent dilatations, with risk of complications. These patients have no other option for management except for surgery. Self expanding plastic stents (SEPS) have been anecdotally used in some patients with a high incidence of migration leading to stent removal. Polydioxanone biodegradable stents have recently been introduced in the UK and this is a report of
www.giejournal.org
0-IIb esophageal carcinoma underwent ESD. Two cultured autologous oral mucosal epithelial cell sheets were transplanted to the 2/3 circumferential ulceration. Four weeks after ESD, complete healing was observed with no sign of constriction. Conclusions: Based on these findings, it is concluded that this treatment promotes wound healing and prevent inflammation and constriction after EMR/ESD, thereby improves post-operative quality of life of patients.
M1484 Buried Glandular Mucosa After Radiofrequency Ablation of Dysplasia in Barrett’s Esophagus Kenneth E. Fasanella, Alyssa M. Krasinskas, Jon M. Davison, Asif Khalid, Kevin McGrath Background: Radiofrequency ablation (RFA) is an accepted modality for endoscopic treatment of dysplastic Barrett’s esophagus. Neosquamous mucosal ingrowth overlying persistent intestinal metaplasia, known as buried glandular mucosa, or ‘‘buried Barrett’s,’’ has been observed after other endoscopic ablative techniques. However, there have been no reports of this finding in surveillance biopsies after RFA. Methods: We identified all patients treated at our center for Barrett’s esophagus using the HALO ablation system. Patients were excluded if they had been treated with other ablation modalities, or if no follow-up biopsies were available. Seattle protocol biopsies were obtained of the length of treated esophagus between 6 and 12 weeks after the most recent RFA. Biopsies were interpreted by expert pathologists at our institution. Buried glandular mucosa was defined as specialized columnar epithelium beneath a layer of squamous epithelium with no communication with the surface. Follow-up was defined as the time from first RFA treatment to most recent biopsy. All patients were treated with twice daily PPI for at least 6 weeks after RFA. Results: A total of 41 patients were identified and 27 were included in the study. Fourteen patients were excluded due to a history of treatment with other ablation modalities (8) and lack of follow-up pathology (6). The median age was 61 years (interquartile range (IQR); 55, 74) and 70% were male. The median Barrett’s segment length was 2 cm (IQR 0.5, 6). The cohort included 3 patients with non-dysplastic Barrett’s, 5 with low-grade dysplasia (LGD), and 19 with high-grade dysplasia (HGD), 6 of whom also had intramucosal adenocarcinoma. Thirteen of these had undergone EMR prior to RFA. Three underwent circumferential ablation only, 18 underwent focal ablation only, and 6 underwent step-wise circumferential and focal RFA. The median number of treatment sessions was 2 (IQR 1, 2) and median follow-up was 6 months (IQR 5, 11). Buried glandular mucosa was reported in 4 patients (14.8%); 3 of these patients initially had HGD and one had LGD. RFA was repeated in all 4 patients. In one, buried glandular mucosa was not observed on Seattle protocol biopsies on three subsequent occasions. In the others, repeat surveillance biopsies have not yet been obtained. Conclusions: Buried glandular mucosa can be seen in surveillance biopsies after treatment with RFA for dysplastic Barrett’s esophagus. As RFA is well tolerated, patients with this finding can be retreated. The clinical importance of this entity remains to be determined and further follow-up will be necessary to determine clearance rates of these changes.
M1485 Treatment of Malignant Gastro-Duodenal Obstruction Using a Nitinol Self Expanding Metal Stent - An International Prospective Multicenter Experience Guido Costamagna, Andrea Tringali, Julius Spicak, John M. Shaw, Massimiliano Mutignani, Andre Roy, Erik Johnsson, Eduardo Guimara˜es H. De Moura, Spencer Cheng, Thierry Ponchon, Max Bittinger, ´ Laugier, Juha Saarnio, Helmut Messmann, Horst Neuhaus, Rene Francisco Igea Arisqueta Objectives: To document technical and clinical success, and complications associated with use of the WallFlexÔ Duodenal Stent (Boston Scientific Corp, Natick, USA) for the palliative management of malignant gastro-duodenal obstruction per standard of practice in a large international multi-centric experience. Stent performance is documented in the largest prospective series conducted to date. Methods: A web-based registry is conducted at 12 endoscopy centers in 10 countries. Follow-up to 9 months is ongoing. An interim analysis is presented. Results: 202 patients (49% male, mean age 70) were enrolled. Most common causes of the stricture were pancreatic cancer (51%), gastric cancer (18%), and duodenal cancer (10%). Stent length was 9 cm (53%), 6 cm (38%), or 12 cm (9%). Technical success was achieved in 96% (193/202). Gastric Outlet Obstruction (GOO) improved from 14% of patients at Baseline tolerating soft solids or low
AB254 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
residue/normal diet to 84% at 15 days, 86% at 30 days, 81% at 90 days, and 79% at 180 days. At 90 days post stent placement compared to Baseline, symptoms of postprandial epigastric tenderness, nausea and vomiting improved in 50%, 55% and 69% of patients respectively and did not worsen in 95% for all three symptoms. The most significant complications to date include stent migration (3%), stent fracture (0.5%), perforation (0.5%), cholangitis (1%), pancreatitis (0.5%), and GOO due to tumor ingrowth (10%), tumor overgrowth (3%) or food impaction (2%). Retreatment occurred in 19 patients (13%); 16/19 received another self-expanding metal stent. To date 59% (119/202) patients died, none due to stent or stenting related complications. Conclusion: Preliminary results from this International Registry related to the WallFlexÔ Duodenal Stent, confirm the effectiveness of the endoscopic treatment of GOO with SEMS with acceptable complication profile. Endoscopic re-treatment of malfunctioning (ingrowth/overgrowth) or migrated SEMS is possible.
M1486 Size Matters - SEMS in Pancreatic Necrosis Georg F. Kaehler, Sebastian Belle, Peter H. Collet Background: After H. Seifert proposed endoscopic transgastric debridement many endoscopists carried out pancreatic necrosectomies. Mostly complete cleansing is not achievable in the first session. More than one flap Stent will be changed every session and sometimes the patients need additional rinsing tubes. Methods: Herein we describe the use of a special metallic stent which was designed to keep the pancreaticogastrostomy open in 3 cases. It is a self expanding metal mesh stent with 50 mm length and 20-25 mm diameter. The indication for necrosectomy was made due to infected necrosis in all cases. The decision to use a SEMS was insufficient therapy with flap stents in two cases and visible solid character of the necrosis in the us in the remaining. After establishing of a cystogastrostomy in two cases and one cystoduodenostomy we dilated the cystoenterostomy with a balloon up to 20 mm. Visible and mobile necrotic material was extracted gently with a Dormia basket. Treatment was defined as intervall from implantation of the SEMS until explantation as shown in the table. If no more necrosis was visible the SEMS was removed. Results: In all cases the pancreatic necrosis could be resolved. In a treatment period of 7-8 d with 2-3 endoscopic procedures we achieved clinical success in all cases without major complications. Discussion: In our knowledge this is the first report about the use of metallic stents for transgastric necrosectomy of the pancreas. We conclude from this observation that SEMS promosing new tool. It seems to us that SEMS accelerate healing and are more convenient to the patient.
onset to Age therapy Indication
Treatment period complication
65 73
59 d 144 d
infected necrosis infected necrosis
7d 8d
42
791
infected necrosis/ pain
7d
Endoscopic sessions
none transitory gastric outlet obstruction none
3 3
2
M1487 Biodegradable Stents in Refractory Benign Oesophageal Strictures - First Report of 4 Patients from UK Anjan Dhar, Joanne H. Topping, Emma Johns, Denise O’Neill Introduction: Benign peptic strictures can sometimes be refractory to endoscopic dilatations, with patients requiring frequent dilatations, with risk of complications. These patients have no other option for management except for surgery. Self expanding plastic stents (SEPS) have been anecdotally used in some patients with a high incidence of migration leading to stent removal. Polydioxanone biodegradable stents have recently been introduced in the UK and this is a report of
www.giejournal.org