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Can Endoscopic Features Identifying the Last Endoscopic Band Ligation Session Before Gastroesophageal Variceal Eradication?
Su1101
Table 2= Distribution of GOVs in both groups
USE OF INDOCYANINE GREEN (ICG) FLUORESCENCE IN MINIMALLY INVASIVE ESOPHAGECTOMY TO ASSESS CONDUIT VASCULARITY Ian Yu Hong Wong, Siu Y. Chan, Daniel King Hung Tong, Kwan Kit Chan, Claudia Wong, Tsz Ting Law, Simon Law Introduction: Poor perfusion of the organ used to restore intestinal continuity after esophagectomy can lead to anastomotic leaks and even conduit necrosis. Intraoperative assessment of vascularity by visual inspection alone may not be adequate. Indocyanine green (ICG) florescence imaging may be useful in aiding this assessment. This is a study investigating the utility of this method as applied in minimally invasive esophagectomy. Methods: Patients who underwent esophagectomy with stomach or right ileo-colonic conduit used to restore intestinal continuity were recruited. In addition to visual inspection of the gastric or ileocolonic conduit intraoperatively, ICG florescence imaging was used as an additional adjunct to assess vascularity. This was correlated with postoperative outcome. Other morbidities were also captured. Results: From October 2014 to December 2015, 33 patients were recruited in the study; 29 of whom had gastric conduits and 4 had right ileo-colonic loops. Eight gastric conduits had suboptimal blood supply judged on ICG fluorescence imaging. With subsequent resection of the relatively ischemic portion of the gastric conduit before construction of the esophageal anastomosis, good postoperative outcome was achieved. Only one patient had an anastomotic leak, which was minor and easily managed. The reason for leak was most likely related to anastomotic technique rather than poor vascularity. No patient had conduit necrosis. There was no postoperative mortality. Using software to analyze conduit perfusion, gastric conduits with poor perfusion had reduced rates of ICG ingress and egress, as shown by fluorescence measurements. Conclusions: ICG fluorescence imaging is a potentially useful intraoperative adjunct in assessment of vascularity of the conduit used for esophageal replacement. More objective numerical criteria should be developed in the future in addition to simple visual assessment.
Su1103 REFLUXASSOCIATED INJURY OF THE REMANT ESOPHAGUS AFTER ESOPHAGECTOMY AND GASTROINTESTINAL FUNCTION TESTING USING THE NEW LARYNGOPHARYNGEAL PH PROBE IN A HUMAN REFLUX MODEL Jessica Leers, Hans F. Fuchs, Sebastian Brinkmann, Felix Berlth, Martin Maus, Wolfgang Schröder, Christiane Bruns Introduction: Gastro-esophageal reflux is a common problem following esophagectomy and reconstruction with gastric interposition. Due to the loss of the lower esophageal sphincter and other anatomical alterations these patients can ideally serve as a human reflux model. Aim of this study is to further evaluate the role of laryngopharyngeal PH monitoring (Restech) in this reflux model and to correlate the results with conventional esophageal pH monitoring. Methods: An research grant application for this prospective clinical trial was submitted and approved by our academic center (project no. 176/2016). All patients undergoing esophagectomy are prospectively entered in our IRB approved database. All patients undergo a routine check-up program with yearly surveillance endoscopies and further exams following esophagectomy. Only patients with a complete check-up program and reflux symptoms were included into this study and were evaluated using 24-h laryngopharyngeal and concomitant esophageal pH-monitoring. Subsequently, the relationship between the two techniques was evaluated. Results: We enrolled the first 15 patients in this prospective study. 69% of the patients had a pathological laryngopharyngeal pH Metry. In these patients laryngopharyngeal reflux was more present in the upright (100%, mean Ryan Score 65.5 [range, 10-316]) than in the supine position (22%, mean Ryan Score 4.22 [range, 2.17-11.49]). All patients with positive supine laryngopharyngeal reflux were also positive for supine esophageal reflux. Esophageal pH metry correlated well with laryngopharyngeal pH metry in this human reflux model. Having a volume of >200 esophagectomies in 2015, we expect a recruitment of 5 patients per month that will prospectively be included in this study and presented. Conclusion: Patients following esophagectomy and reconstruction with gastric interposition do ideally serve as a human reflux model. Interestingly, reflux phases occur mainly in the upright position. Further validation of the laryngopharyngeal pH-Metry seems possible with further recruitment of patients in this study.
Su1102 CAN ENDOSCOPIC FEATURES IDENTIFYING THE LAST ENDOSCOPIC BAND LIGATION SESSION BEFORE GASTROESOPHAGEAL VARICEAL ERADICATION? Stefano Pontone, Cristina Panetta, Rossella Palma, Angelo Antoniozzi, Antonietta Lamazza Introduction: Endoscopic Band Ligation (EBL) is performed to decrease the risk of variceal bleeding. Initially proposed for the treatment of esophageal varices as a method for obtaining hemostasis in acute bleeding, EBL has also been used electively for the prophylaxis of recurrent variceal bleeding. Furthermore, at the consensus workshop of Baveno V it was concluded that either non-selective beta-blockers or band ligation are recommended also for the prevention of a first variceal bleeding of medium or large varices. The aim of this study is to find endoscopic parameters who could alone identify the last EBL before the eradication and the other endoscopic sessions. Patients and Methods: We selected from August 2013 to September 2016, 287 EBL sessions. Among the 287 sessions, we distinguished the ligation that preceded the eradication (Second to last Session) from all the others for each patient who underwent EBL. All patients included were followed from the first upper gastrointestinal bleeding to the variceal eradication. We excluded the first endoscopic session in which the diagnosis was performed and all the endoscopic sessions in which the eradication has not been recorded. The following endoscopic parameters of esophageal varices were recorded: size (F1-F2-F3 according to the Japanese classification), blue tone (the percentage of varices with bluish coloration), and red color signs. Congestive gastropathy was evaluated. Gastric varices were graded as absent or present and were distinguished in GOV and IGV, while red color signs were classified. Bands' number used during ligation was also recorded and was calculated as ≤3 or >3. Results: 95 endoscopic sessions were included. 51 were classified as second to last (Group A), and 44 as other sessions (Group B). The variceal size and red color signs ( χ 2= 0,070) are represented in Tables 1. The blue tone was 97,9% and 100% respectively. The number of arranged bands was ≤4 in 11 and 19 sessions respectively (61,1% vs 82,6 %) and > 4 in 7 and 4 sessions for each group (38,9% vs 17,4%) (χ 2= 0,123) . There were no statistically significant differences in the grade of congestive gastropathy between the two groups (χ 2= 0.432). The distribution of GOVs in each group is represented in Table 3. In the 87,2% of cases GOVs are not detected during the second to last sessions and none session who precede the eradication presented GOV2. (χ 2= 0,019). Conclusions: In our experience the variceal size according to the Japanese classification and the presence of gastroesophageal varices could be considered useful endoscopic indicators that can predict the eradication failure of esophageal varices and can be used to indirectly identify the last session before the variceal eradication. Other studies that include also clinical and biochemical datas are needed. Table 1= Variceal size according to the Japanese Classification. Red color signs classified as absent (-), mild to moderate (+), or diffuse presence in all varices (++).
PER ORAL ENDOSCOPIC MYOTOMY PRODUCES DURABLE IMPROVEMENT IN DYSPHAGIA SYMPTOMS AND PATIENT QUALITY OF LIFE Anahita D. Jalilvand, Jennifer Schwartz, Edward L. Jones, Michael Meara, Jeffrey W. Hazey, Kyle A. Perry BACKGROUND: Laparoscopic Heller myotomy is the gold standard therapy for achalasia due to effective and durable dysphagia relief. While endoscopic pneumatic dilation provides similar short-term outcomes, it often requires repeated treatments which increase the risk of esophageal perforation. Per Oral Endoscopic Myotomy (POEM) combines the advantages of surgical myotomy and pneumatic dilation, but concerns about post-operative reflux and long-term outcomes remain. The objective of this study was to assess the long-term impact of POEM on patient symptoms and quality of life. METHODS: We performed a retrospective review of patients undergoing POEM in 2012 and 2013. Demographic, preoperative, operative and outcome data were collected prospectively and maintained in an IRB approved database. The primary outcome measure was dysphagia relief as measured on a 5 point Likert scale. Secondary outcomes included disease-specific (GERD-HRQL), and global (SF36) quality of life scores, gastroesophageal reflux symptom score (GERSS) and PPI use. Outcomes were assessed at baseline and post-operatively in the clinic setting and by telephone after 1 and 3 years. Data are presented as incidence (%), mean ± SD, or median (range) as appropriate. A p-value <0.05 was considered statistically significant. RESULTS: Twenty-five patients with a primary symptom of dysphagia underwent POEM during the study period. Twenty-four (96%) had achalasia. Patents had an average age of 53.5 ± 18.0 years, BMI of 28.4 ± 5.2, and 52% (n=13) were male. All cases were completed successfully with an OR time of 99 (57-176) minutes. There were no complications and median hospital stay was 1 (1-2) day. Three-year follow-up data was available for 21 (84%) patients. Dysphagia scores improved from 4 (0-5) at baseline to 1 (0-4, p<0.01) after 1 year and 1 (0-5, p<0.01) after 3 years. Four patients (16%) underwent endoscopic dilation during the follow-up period and 2 (8%) required a redo myotomy. GERSS improved from 30 (4-64) at baseline to 7 (0-38, p<0.01) after 1 year and 14 (0-60, p<0.01 ) after 3 years. GERSS (p=0.39) and PPI use (18% vs. 38%, p=0.10) were not significantly different between 1 and 3 years. GERDHRQL improved from 23 (3-43) to 3 (0-29, p<0.01) after 1 year and 6 (1-41, p<0.01) after 3 years. One patient underwent a laparoscopic fundoplication for significant reflux symptoms 2.5 years after POEM. Three years after POEM, patients demonstrated significant improvements in physical function (p=0.02), emotional well-being (p=0.04) and social functioning (p=0.01) compared to baseline. CONCLUSION: POEM provides an effective treatment strategy for achalasia that yields excellent dysphagia relief and improved disease-specific and global quality of life after 3 years. Although associated with post-procedure reflux symptoms in some cases, these are typically well controlled with medical therapy.
*statistically significant
S-1243
SSAT Abstracts
SSAT Abstracts
Su1104
Table 2= Distribution of GOVs in both groups
USE OF INDOCYANINE GREEN (ICG) FLUORESCENCE IN MINIMALLY INVASIVE ESOPHAGECTOMY TO ASSESS CONDUIT VASCULARITY Ian Yu Hong Wong, Siu Y. Chan, Daniel King Hung Tong, Kwan Kit Chan, Claudia Wong, Tsz Ting Law, Simon Law Introduction: Poor perfusion of the organ used to restore intestinal continuity after esophagectomy can lead to anastomotic leaks and even conduit necrosis. Intraoperative assessment of vascularity by visual inspection alone may not be adequate. Indocyanine green (ICG) florescence imaging may be useful in aiding this assessment. This is a study investigating the utility of this method as applied in minimally invasive esophagectomy. Methods: Patients who underwent esophagectomy with stomach or right ileo-colonic conduit used to restore intestinal continuity were recruited. In addition to visual inspection of the gastric or ileocolonic conduit intraoperatively, ICG florescence imaging was used as an additional adjunct to assess vascularity. This was correlated with postoperative outcome. Other morbidities were also captured. Results: From October 2014 to December 2015, 33 patients were recruited in the study; 29 of whom had gastric conduits and 4 had right ileo-colonic loops. Eight gastric conduits had suboptimal blood supply judged on ICG fluorescence imaging. With subsequent resection of the relatively ischemic portion of the gastric conduit before construction of the esophageal anastomosis, good postoperative outcome was achieved. Only one patient had an anastomotic leak, which was minor and easily managed. The reason for leak was most likely related to anastomotic technique rather than poor vascularity. No patient had conduit necrosis. There was no postoperative mortality. Using software to analyze conduit perfusion, gastric conduits with poor perfusion had reduced rates of ICG ingress and egress, as shown by fluorescence measurements. Conclusions: ICG fluorescence imaging is a potentially useful intraoperative adjunct in assessment of vascularity of the conduit used for esophageal replacement. More objective numerical criteria should be developed in the future in addition to simple visual assessment.
Su1103 REFLUXASSOCIATED INJURY OF THE REMANT ESOPHAGUS AFTER ESOPHAGECTOMY AND GASTROINTESTINAL FUNCTION TESTING USING THE NEW LARYNGOPHARYNGEAL PH PROBE IN A HUMAN REFLUX MODEL Jessica Leers, Hans F. Fuchs, Sebastian Brinkmann, Felix Berlth, Martin Maus, Wolfgang Schröder, Christiane Bruns Introduction: Gastro-esophageal reflux is a common problem following esophagectomy and reconstruction with gastric interposition. Due to the loss of the lower esophageal sphincter and other anatomical alterations these patients can ideally serve as a human reflux model. Aim of this study is to further evaluate the role of laryngopharyngeal PH monitoring (Restech) in this reflux model and to correlate the results with conventional esophageal pH monitoring. Methods: An research grant application for this prospective clinical trial was submitted and approved by our academic center (project no. 176/2016). All patients undergoing esophagectomy are prospectively entered in our IRB approved database. All patients undergo a routine check-up program with yearly surveillance endoscopies and further exams following esophagectomy. Only patients with a complete check-up program and reflux symptoms were included into this study and were evaluated using 24-h laryngopharyngeal and concomitant esophageal pH-monitoring. Subsequently, the relationship between the two techniques was evaluated. Results: We enrolled the first 15 patients in this prospective study. 69% of the patients had a pathological laryngopharyngeal pH Metry. In these patients laryngopharyngeal reflux was more present in the upright (100%, mean Ryan Score 65.5 [range, 10-316]) than in the supine position (22%, mean Ryan Score 4.22 [range, 2.17-11.49]). All patients with positive supine laryngopharyngeal reflux were also positive for supine esophageal reflux. Esophageal pH metry correlated well with laryngopharyngeal pH metry in this human reflux model. Having a volume of >200 esophagectomies in 2015, we expect a recruitment of 5 patients per month that will prospectively be included in this study and presented. Conclusion: Patients following esophagectomy and reconstruction with gastric interposition do ideally serve as a human reflux model. Interestingly, reflux phases occur mainly in the upright position. Further validation of the laryngopharyngeal pH-Metry seems possible with further recruitment of patients in this study.
Su1102 CAN ENDOSCOPIC FEATURES IDENTIFYING THE LAST ENDOSCOPIC BAND LIGATION SESSION BEFORE GASTROESOPHAGEAL VARICEAL ERADICATION? Stefano Pontone, Cristina Panetta, Rossella Palma, Angelo Antoniozzi, Antonietta Lamazza Introduction: Endoscopic Band Ligation (EBL) is performed to decrease the risk of variceal bleeding. Initially proposed for the treatment of esophageal varices as a method for obtaining hemostasis in acute bleeding, EBL has also been used electively for the prophylaxis of recurrent variceal bleeding. Furthermore, at the consensus workshop of Baveno V it was concluded that either non-selective beta-blockers or band ligation are recommended also for the prevention of a first variceal bleeding of medium or large varices. The aim of this study is to find endoscopic parameters who could alone identify the last EBL before the eradication and the other endoscopic sessions. Patients and Methods: We selected from August 2013 to September 2016, 287 EBL sessions. Among the 287 sessions, we distinguished the ligation that preceded the eradication (Second to last Session) from all the others for each patient who underwent EBL. All patients included were followed from the first upper gastrointestinal bleeding to the variceal eradication. We excluded the first endoscopic session in which the diagnosis was performed and all the endoscopic sessions in which the eradication has not been recorded. The following endoscopic parameters of esophageal varices were recorded: size (F1-F2-F3 according to the Japanese classification), blue tone (the percentage of varices with bluish coloration), and red color signs. Congestive gastropathy was evaluated. Gastric varices were graded as absent or present and were distinguished in GOV and IGV, while red color signs were classified. Bands' number used during ligation was also recorded and was calculated as ≤3 or >3. Results: 95 endoscopic sessions were included. 51 were classified as second to last (Group A), and 44 as other sessions (Group B). The variceal size and red color signs ( χ 2= 0,070) are represented in Tables 1. The blue tone was 97,9% and 100% respectively. The number of arranged bands was ≤4 in 11 and 19 sessions respectively (61,1% vs 82,6 %) and > 4 in 7 and 4 sessions for each group (38,9% vs 17,4%) (χ 2= 0,123) . There were no statistically significant differences in the grade of congestive gastropathy between the two groups (χ 2= 0.432). The distribution of GOVs in each group is represented in Table 3. In the 87,2% of cases GOVs are not detected during the second to last sessions and none session who precede the eradication presented GOV2. (χ 2= 0,019). Conclusions: In our experience the variceal size according to the Japanese classification and the presence of gastroesophageal varices could be considered useful endoscopic indicators that can predict the eradication failure of esophageal varices and can be used to indirectly identify the last session before the variceal eradication. Other studies that include also clinical and biochemical datas are needed. Table 1= Variceal size according to the Japanese Classification. Red color signs classified as absent (-), mild to moderate (+), or diffuse presence in all varices (++).
PER ORAL ENDOSCOPIC MYOTOMY PRODUCES DURABLE IMPROVEMENT IN DYSPHAGIA SYMPTOMS AND PATIENT QUALITY OF LIFE Anahita D. Jalilvand, Jennifer Schwartz, Edward L. Jones, Michael Meara, Jeffrey W. Hazey, Kyle A. Perry BACKGROUND: Laparoscopic Heller myotomy is the gold standard therapy for achalasia due to effective and durable dysphagia relief. While endoscopic pneumatic dilation provides similar short-term outcomes, it often requires repeated treatments which increase the risk of esophageal perforation. Per Oral Endoscopic Myotomy (POEM) combines the advantages of surgical myotomy and pneumatic dilation, but concerns about post-operative reflux and long-term outcomes remain. The objective of this study was to assess the long-term impact of POEM on patient symptoms and quality of life. METHODS: We performed a retrospective review of patients undergoing POEM in 2012 and 2013. Demographic, preoperative, operative and outcome data were collected prospectively and maintained in an IRB approved database. The primary outcome measure was dysphagia relief as measured on a 5 point Likert scale. Secondary outcomes included disease-specific (GERD-HRQL), and global (SF36) quality of life scores, gastroesophageal reflux symptom score (GERSS) and PPI use. Outcomes were assessed at baseline and post-operatively in the clinic setting and by telephone after 1 and 3 years. Data are presented as incidence (%), mean ± SD, or median (range) as appropriate. A p-value <0.05 was considered statistically significant. RESULTS: Twenty-five patients with a primary symptom of dysphagia underwent POEM during the study period. Twenty-four (96%) had achalasia. Patents had an average age of 53.5 ± 18.0 years, BMI of 28.4 ± 5.2, and 52% (n=13) were male. All cases were completed successfully with an OR time of 99 (57-176) minutes. There were no complications and median hospital stay was 1 (1-2) day. Three-year follow-up data was available for 21 (84%) patients. Dysphagia scores improved from 4 (0-5) at baseline to 1 (0-4, p<0.01) after 1 year and 1 (0-5, p<0.01) after 3 years. Four patients (16%) underwent endoscopic dilation during the follow-up period and 2 (8%) required a redo myotomy. GERSS improved from 30 (4-64) at baseline to 7 (0-38, p<0.01) after 1 year and 14 (0-60, p<0.01 ) after 3 years. GERSS (p=0.39) and PPI use (18% vs. 38%, p=0.10) were not significantly different between 1 and 3 years. GERDHRQL improved from 23 (3-43) to 3 (0-29, p<0.01) after 1 year and 6 (1-41, p<0.01) after 3 years. One patient underwent a laparoscopic fundoplication for significant reflux symptoms 2.5 years after POEM. Three years after POEM, patients demonstrated significant improvements in physical function (p=0.02), emotional well-being (p=0.04) and social functioning (p=0.01) compared to baseline. CONCLUSION: POEM provides an effective treatment strategy for achalasia that yields excellent dysphagia relief and improved disease-specific and global quality of life after 3 years. Although associated with post-procedure reflux symptoms in some cases, these are typically well controlled with medical therapy.
*statistically significant
S-1243
SSAT Abstracts
SSAT Abstracts
Su1104