- Email: [email protected]
Clinical response after Stretta procedure for GERD reflects improvement in esophagel acid exposure
control and predictability were each provided at high or low levels. Eighty participants were assigned to one of the four groups. Those with high control were given a hand-held device that could stop the drum's rotation at their discretion; those with low control passively viewed the rotation of the dram as it was operated by an experimenter from an adjacent room. Those with high predictability were told for exactly how long the drum would rotate, and were given updates every 2 rain of the amount of time remaining; those with low predictability were not given any such information. Subjective symptoms of motion sickness (SSMS) and electrogastrograms (EGGs) were obtained during a 6 rain baseline period and a subsequent 16 rain drum rotation period. Results: SSMS scores were significantly lower among participants with high control than among those with low control, and were stgnificandy lower among participants with high predictability than among those with low predictability. Estimates of gasmc tachyarrhythmia obtained from the EGG during drum rotation were significantly lower among participants with high predictability than among those with low predictability Although gastric tachyarrhythmia during drum rotation was lower among participants with hgh control than among those with low control, the difference was not statistically significant Conclusions: The results of this study suggest that stronger perceptions of control-and predictability may temper the development of nausea and dysrhythmic gastric activity during exposure to provocative motion. Participants who knew they were able to stop the drum's rotation as soon as they deemed necessary, and those who knew how long they needed to endure the drum's stressful stimulation tended to develop fewer and less severe symptoms of nausea and motion sickness. These results may have implications for the effective, nonpharmaco[ogical treatment of nausea in various evocative contexts.
(cm)
50mmH9
-3
-2
Posterior
/rtla[al apex
-1 f FP
0 1 EGJ 2 Hiatal reoai 3 4
Washers
SCJ clipt Wrap
748 Acid and Non-Acid Gastroesophageal Reflux After Endoscopic Gastroplication. Evaluation of The Antireflux BarrierFunction With 24Hs-pH-Impedance .Kin Zhang, Jan Tack, Jozef Janssens, Daniel Sifrim
746
Association of Anterior Cingulate Cortex (ACC) Activation with Psychosocial Distress and Pain Reports
Several endoscopic antireflux procedures have been developed to modify the anatomy and improve the function of the antirreffux barrier at the gastroesohagealjunction. The evaluation of efficacy of these procedures mainly considered changes in esophageal acid exposure, symptoms and quality of life These parameters are highly influenced by the esophageal clearance function and patient's sensitivity. A more specific evaluation of the antireflux burner function, after any intervention, should include the total number of times the barrier failed. The number of acid reflux episodes, traditionally measured during 24hs-pHmetry, does not considered barrier failures underlying less acidic or non-acid reflux. Combined pH-impedance recordings allows detection of all types of reflux (acid, non-acid and gas) and therefore, a more complete quamihcarion of the antireflux barrier failures. We aimed to assess the antireflux burner function before and after endoscopic gastroplication in 14 patients with GERD, using 24hs-pH-impedance recordings. Methods: Patients were evaluated 'oft~antisecretory medication, before and 6 months after the Endocinch| procedure. Analysis of the pH-impedance recording included total number of reflux events (acid + minor acid + non-acid), gas-liquid composition, proximal extent of reflux and total acid exposure. Results: Endoscopic gastroplicadon decreased the number of barrier failure events (total reflux) in 9 patients (64%). Both acid and non acid reflux events were reduced by 50% but the percent of reflux events containing gas or those reaching the more proximal esophagus were unaffected by the antireflux procedure. In these patients, the total esophageal acid exposure was marginally reduced. Conclusions: Measuring of all types of reflux events (acid, non acid and gas) allows a precise and objective evaluation of the effect of therapeutic interventions on the antireflux barrier function.
Yehuda lhngel, Douglas A. Drossman, Jane Leserman, Weili Lin, Hui l_iu, Brent A. Vogt, William E. Whitehead Previous studies using fMRI in IBS reported differences in regional brain activation between IBS and healthy controls (Naliboff, 2001; Mertz, 2000) We have also reported differences in brain activation among patients with and without a history of abuse (Ringel, DDW 2002, 2003) The factors that contribute to these differences and the association of brain activation with psychosocial distress and pain reports have not been described. Aim: To assess the association of psychological factors and pain experience with brain activation of the anterior cingulate cortex [Perigenua[ (pACC) and midcingufate cortex (MCC)] dunng rectal balloon distention Methods: We studied 20 right-handed female subjects among l0 patients with IBS (5 with and 5 vathout abuse history), and 10 controls without IBS (5 with and 5 wuhout abuse) Psychosocial assessment included standardized measures of Global Severity Index (GSI) of SCL-90, maladaprive coping (Catastrophizing subscale of coping strategies questionnaire, Drossman Psychosom Med. 2000) and stressful life events (Leserman Am J Psychiatry 2000). fMRI images (15 T) and subjective rating of pain (on a 0-5 scale) were obtained during baseline, 15mmHg (non-painful), 50mmHg (painful), and alternating pressures of 15/50mmHg distensions. Small volume correction analysis was used to measure the activation at pACC and MCC. The association between the activation at a specific region and the subjects reports of pain, and certain psychological variables were assessed by Pearson correla tions. Results: 1) pACC activation positively correlated wuh maladaptive coping (r = 0.53, p=004), and subjective pain reports to rectal distension (r=0.48, p=0.05); 2) More stressful life events (in the past 6 months) was positively correlated with htgber MCC activation (r = 052, p = 0 0 3 ) There was no correlation of the brain activation with the GS1 of SCL-90. Conclusions: This study provides novel evidence for an association between cingulate brain activation, an area associated with cemra[ pain modulation, psychosocial distress and pain reporting. This may explain the clinical association of more severe pain among patients with psychosocial distress
Succeeded patients Failed I)~llmts
Pre-
endocinch Postendocinch
Pre-
Total reflux
Acid reflux
Acid esposure
71(519t) 32(23-
41(1870) 19(11.
9.3%(4,1%- 58%(42%20.6%) 75%) 4`9%(2,3%- 46%(26%-
60(41-
35(26- 17.9%(6.5%- 58%(11%-
61)*
45)*
9.8%)
Proximal symptom extence score
Pressure and High Frequency IntraluminalUhrasonography (HFIUS) Morphology of Nissen Fundoplication (FP) Sunil Y. joseph, Qing Zhang, Ikuo Hirano, Raymond Joehl, James Brasseur, Peter J Kahrilas
7(2.5`9.5)
65%)
endocinch 89) 65) 359%} 86%) Post95(39- 27(15- 11,8%(1.8%- 56%(15% endocinch 117} 68) 16,9%) 83%) 'valuesare: media(25%-75%). * p<0.05 vs pre-endocinch, paired t lest.
747
9(4,5-15)
12[6-19) 8(3-18}
749
Aim: To correlate .the pressure and HFIU5 characteristics of PP in relation to surgically phced markers. Methods: 8 GERD patients undergoing FP had metal markers placed on FP sutures (washers), at the apex of the hiatus (clip), at the hiatal repair (washer), and an endoscopic clip placed at the SCJ. Subjects were studied 16+/-6 months post FP with HF1US(20 MHz probe) followed by fluoroscopy with concurrent manometry. The manometer had 8 recording sites at the same axial level dispersed radially. Axial level 0 was the midpoint of the respiratory inversion zone (RIZ). The EGJ was defined by HFIUS as the most distal locus at which a circumlerential circular muscle layer was imaged. Results: 6 of the 8 patients had intact FP, 1 had a slipped Nissen and paraesophageal hernia and 1 had a disrupted FP. Analysis was performed on the 6 with intact FP. EGJ location (+ 1 lmm) correlated well w.th the SCJ (+8ram) (r= .97) and the median position of the RIZ correlated well with the apex of the hiatus (r = .99) In the patients in whom all surgical markers were imaged, mean FP washer separation was 6.3 mm whereas the FP length by HF1US was 33 mm such that it aligned with the proximal washer and extended 25 mm distal to the 2nd. Maximal 5GJ pressure was 22mmHg and was located 3ram (r 4-14) distal to the EGJ but closely correlated to the midpoint between the apex of the diaphragm and the level of the crural repair (r = .99). FP disruption was evident by obviously mislocated fundoplication washers SlippedNissen was demonstrated by HFIUS localization of the EGJ above the PP. Paraesophagea[hernia was characterized by a highly asymmetric esophageal pressure. Conclusions: 1) HFIUS can reliably locate the anatomical EGJ, position and length of fundoptication, FP disruption, and slipped Nissen, 2) HFIUS may be a useful clinical tool in evaluating the integrity of FP.
Clinical response after Stretta procedure for GERD reflects improvement in esophageal acid exposure George Triadafilopoulos Background: Radiofrequency energy delivery (Stretta procedure) has been shown, in open label and sham controlled studies, to be safe and effective for the management of GERD. One criticism, however, has been the theory that the primary mechanism of action of Stretta is ablative denervation of the esophageal body, rather than a reduction in esophageal acid exposure because of augmentation of the anti-reflux barrier. To resolve this question, we sought to determine if there was a positive correlation between the improvement in GERD outcomes and esophageal acid exposure. Methods: The Stretta Open Label Trial database represents 118 patients treated in 1999 at 14 U.S. institutions. While the results of this trial have been previously reported, we performed subgroup analyses based on patient outcomes for GERD-HRQL (0-50), heartburn seventy (0-5), daily PPI use (yes/no), and satisfaction (0-5) A response for each subgroup was defined as GERD-HRQL less than 10, heartburn less than 1, no daily PPl use, and satisfaction more than 4. Baseline (before Stretta) and follow-up (6 months after Stretta) esophageal acid exposure (proximal and distal) were then compared for each responder and non-responder group. Results: All responder subgroups demonstrated significant improvement in both proximal and distal acid exposure. Nonresponder subgroups, however, either did not demonstrate improvement in proximal or distal acid exposure or had a sigmficantly smaller improvement versus the responder subgroup. For responder groups, symptom improvement correlated with improvement in acid exposure, while in non-responder groups there was no correlation Proximal acid exposure was more likely to be improved and more likely to be normalized than distal acid exposure for the responder group, suggesting that this componem of reflux contributes perhaps more
A-97
AGA
Abstracts
significantly to GERD symptoms in this cohort. The relationship between % time with pH less than 4 and responder status by GERD-HRQL is shown in Table. Conclusion: Clinical responders to the Stretta procedure, as defined by the subgroup parameters, have significant improvements and normalization in both proximal and distal esophageal acid exposure, while non-responders either have no improvement or less improvement. This data refutes the theory that Stretta relieves symptoms and improves patient satisfaction by desensitizing the esophageal body.
Clinical and fun~onal ouCon~ ~
R#oml
falinre rate after 4/24 months LES preoperative (mmHg) after 4 months afinr 2 yam DeMaester Score preop. erathte after 4 mot~kt u#er 2 years Dyuphagia preoperat~a (number of pa6ents) alter 4 months after 2 yea~
Dintal medlm % time with pH len than 4 bofore and alter StreUa Relponder Non.relpondw
10.4 10.0
4.3 7.7
750 Effect of Radiofrequency Ablation on Gastric Dysrhythmias and Gastric Emptying in Patients with Gastroesophageal Reflux Disease (GERD) and Functional Dyspepsia Mark Noar, Lihua Xu, Kenneth L. Koch
in 200 patients wi~ GERD
NisslmToup~ IPvalue Dyumo-
my
11/15
4/8
ns
10/15
11/14
ns
11.3
13,6
ns
8.9
10,1
ns
16.6 14.7 45,4
16.9 13.5 39.1
ns
16,5
13.4
ns
14,0
11.5
ns
4t.6
43,9
<0,01 <0.05 ns
12.5 19.1 14
4,8 12.8 11
<0.05 ns ns
11.2 16.7 16
8.0 20.7 22
ns ns --0.03
24 4
7 3
<0.01 ns
20 9
10 4
<0.05 ns
752
Gastric neuromuscular dysfunction has a role in GERD and in functional dyspepsia symptoms. Gastric dysrhythmias have been recorded in patients with dyspepsia who also have GERD. Radiofrequency ablation (RFA) is used to treat GERD and may work by ablating vagal sensory neural pathways. AIMS: To determine the effect of RFA treatmem of the lower esophageal sphincter/cardia region on t) Gastric myoelectrical activity; 2) Gastric emptying (GE); and 3) Gastric capacity in patients with GERD plus dyspepsia (GERD + ). METHODS: 43 patients (31 women and 12 men, ages 19-78 yr.) referred to a community-based GI practice for refractory GERD underwent endoscopy and electrogastrogram (EGG) with water load tests (WLT) and GE prior to RFA (Stretta procedure). Endoscopies showed Grade 1 esophagitis or normal mucosa. EGG with water load test was performed in standard fashion and diagnoses (bradygastria, tachygastria, mixed dysrhythmia or normal) were made on the basis of EGG rhythm strips and computer analysis. GE tests used isotope-labeled eggs. RESULTS: Stretta procedure was performed successfully in each of the 43 patients. Pre-RFA EGG diagnoses were: tachygastria in 47%, bradygnstria in 11%, mixed dysrhythmia in 14% and normal in (12/43) 28%. The EGG with WLT was repeated 7.3 months after the RFA treatment. Post-RFA diagnoses were: tachygastria in 28%, bradygastria in 4%, mixed dysrhythmia in 14% and normal in (23/43) 53% (P<0.03). Overall, 35% (11/31) of the patients with baseline gastric dysrhythmias convened to normal EGG patterns after RFA. 8/20 (43%) of tachygastriasconverted to normal 3 cpm rhythm. These patients had significant improvement in GE (47% to 85% emptied, P<0.01), compared with patient normal EGG (67% to 82%, P=0.16). Normal baseline EGGs were found in 12 patients. Pre-procedure WLT volume was 444 +/- ml and post-procedure volume was 389 +/- ml (P
Lower Esophageal Sphincter Function After Endoscopic EVOH Polymer Injection for GERD Treatment: 1 Year Results Hubert Louis, Winfried Voderholzer, Olivier Le Moine, David Silverman, Jacques Deviere Introduction: Implantation of ethylene-vinyl-alcohol polymer (EVOH) in the lower esophageal sphincter (LES) improves symptoms in patients with gastroesophageal reflux disease (GERD). Aims & Methods : To analyze the effect of EVOH injection on the LES function, 13 patients (4 male, 9 female) with GERD (GERD symptoms controlled with PPI, 0%pH < 4 > 5) underwent esophageal manometry 30 rnin before and 90 mill after a semiliquid meal, before and 1 month after EVOH implamation. Follow-up was obtained at 6 and 12 momhs for 7 patients. Twenty-four hour ambulatory pH-metry was performed before and 6 months after implantation. Results: (Table: median (range), *p
%time pH <4
751
Reflux eplsodez/24h GERD HQRL score N patient=
A Prospective Randomized Trial to Study the Effect of Esophageal Motility on Long-Term Results of Nissen and Toupet Fundoplication for Gastroesophageal Reflux Disease. Results of a 2 Years Follow-Up Christians Fibbe, Jutta Keller, Alice Emmermann, Carsten Zornig, Peter Layer
Pre-trea'mnm~
1 month
6 months
12 months
10,4 (7-22)
16.8 (6-32)"
11.1 (8-23)
14,4 (6-29)
.O (0-1)
2.8 (0-18)* .0 (0-9) 3 (2-5)
1.7 (0-7)*
3,2 (0-7)*
3 (0-7) 3 (2-4)
12.5 163 21 (5-27) 13
8,5 (0-28)* 13
1 (0-3)
1 (04)
3 (2-5)
3.3 (2-4)
7.1 77 11.5 (0-28)"
3 (0-22)*
7
7
753
Background: it is uncertain if amirs flux surgery can normalize esophageal motility, or if adjusting surgical techniques to underlying motor disturbances (tailored concept) improves clinical outcome. Aims: to assess the results which can be achieved by tailoring the antireflux procedure to the esophageal motor function in patients with GERD. Methods: Between may 1999 and may 2000, 200 patients (121 male, 79 female; median age 56 (range 20-80) years) with long-term medical treatment for GERD were randomized prospectively to either a partial wrap Toupet (T;n = 100) or a 360 degree Nissen fundoplication (N;n = 100) ignoring preoperative esophageal motility.In each treatment group an equal number of patients had normal or impaired esophageal motility. All underwent esophageal function testing (upper GI endoscopy, esophageal manometry, 24['1pH-monitoring and clinical assessment) preoperatively and as a postoperative follow-up 4 and 24 months later. Results: Dysphagia was more common in the early follow up after N especially in the normal motility group, a difference which disappeared vclth time. There was no difference in the cumulative relapse rate (30% N vs 22% T). The increase in reflux recurrence after 2 years corresponded to a decrease in LES resting tone over the time independem of esophageal motor function or the procedure performed. Despite reflux control postop, esophageal motility remained unchanged in 85%. Conclusions: N and T equally well and durably control GERD independent of esophageal motility, although the efficacy of reflux comrol seems to diminish over the time. Only in the early postoperative course fewer symptoms occur in those having a T. Both procedures do not normalize esophageal dysmotility. Therefore esophageal dysmotility may not require tailoring of surgical management.
AGA Abstracts
Niuen and Toupet f u n d o ~
Niuen Toupet pvalue Botil-
Aggressive Surgical Treatment for Recurrent Hepatocellular Carcinoma Akira Kobayashi, Shinichi Miyagawa, Akimasa Matsnshita, Takenari Nakata, Kazuhiko Nomura, Terumasa Noike, Shiro Miwa, Kazuhiro Hanazaki, Kan Nakagawa Background: Advancement in perioperative management and operative techniques has improved the results of liver resection for HCC dramatically. However, the long-term prognosis remains unsatisfactory because of a high incidence of recurrence. Although several studies have advocated repeat liver resection as the most effective treatment modality for patients with intrahepatic recurrent HCC, obviously no conclusion can be drawn about the survival benefit of repeat bepatectomy, because the number of patients was small. Aim: The aim of this study is to evaluate the outcome of 80 repeat hepatectomies and to clarify the role of this treatment strategy. Patients and Methods: Between January 1990 and December 2001, we have performed 404 curative hepatectomies: 324 initial and 80 repeat liver resections, on 337 HCC patients. The median follow-up period after initial hepatectomy was 36 momhs (mean, 44 months; range, 0.4-137 months), and recurrence was confirmed in 214 patients (66%). The liver was the only site in 179 patients. Repeat (second) liver resection was performed in a total of 60 patients: 52 who underwent the initial hepatectomy at our hospital and 8 who underwent their initial liver resection at other hospitals. Results: The mean and median blood loss in the 60 patients who underwent second hepatectomy was 584 ml and 450 ml, respectively (range, 46-2850 ml). Only 2 patients (3%) required red blood ceil transfusion perioperatively. There were no operative or hospital deaths. The mean and median follow-up periods after repeat hepatic resection were 40 months and 39 months, respectively (range, 1-110). The 1-, 3-, and 5-year survival rates after the second hepatic resection were 96.7%, 73.9%, and 52.9, respectively. Recurrent HCC after the second hepatectomy was found in 40 patients. Of them, 13 patients and another 5 patients who had their first and second liver resections at other institutions underwent a third liver resection. The mean and median blood loss during the third liver resection was 746 ml and 475 ml, respectively (range, 60-2300 ml). There were no in-hospital deaths. Recurrence in the liver remnant after the third operation was confirmed in 11 patients, and fourth operation was performed in 2 of them. These 2 patients are currently alive, 74 months and 105 months, respectively after their initial hepatectomy. Conclusion: Repeat hepatic resection is a safe and effective treatment modality for patients with intrahepatic recurrence of HCC.
A-98
(cm)
50mmH9
-3
-2
Posterior
/rtla[al apex
-1 f FP
0 1 EGJ 2 Hiatal reoai 3 4
Washers
SCJ clipt Wrap
748 Acid and Non-Acid Gastroesophageal Reflux After Endoscopic Gastroplication. Evaluation of The Antireflux BarrierFunction With 24Hs-pH-Impedance .Kin Zhang, Jan Tack, Jozef Janssens, Daniel Sifrim
746
Association of Anterior Cingulate Cortex (ACC) Activation with Psychosocial Distress and Pain Reports
Several endoscopic antireflux procedures have been developed to modify the anatomy and improve the function of the antirreffux barrier at the gastroesohagealjunction. The evaluation of efficacy of these procedures mainly considered changes in esophageal acid exposure, symptoms and quality of life These parameters are highly influenced by the esophageal clearance function and patient's sensitivity. A more specific evaluation of the antireflux burner function, after any intervention, should include the total number of times the barrier failed. The number of acid reflux episodes, traditionally measured during 24hs-pHmetry, does not considered barrier failures underlying less acidic or non-acid reflux. Combined pH-impedance recordings allows detection of all types of reflux (acid, non-acid and gas) and therefore, a more complete quamihcarion of the antireflux barrier failures. We aimed to assess the antireflux burner function before and after endoscopic gastroplication in 14 patients with GERD, using 24hs-pH-impedance recordings. Methods: Patients were evaluated 'oft~antisecretory medication, before and 6 months after the Endocinch| procedure. Analysis of the pH-impedance recording included total number of reflux events (acid + minor acid + non-acid), gas-liquid composition, proximal extent of reflux and total acid exposure. Results: Endoscopic gastroplicadon decreased the number of barrier failure events (total reflux) in 9 patients (64%). Both acid and non acid reflux events were reduced by 50% but the percent of reflux events containing gas or those reaching the more proximal esophagus were unaffected by the antireflux procedure. In these patients, the total esophageal acid exposure was marginally reduced. Conclusions: Measuring of all types of reflux events (acid, non acid and gas) allows a precise and objective evaluation of the effect of therapeutic interventions on the antireflux barrier function.
Yehuda lhngel, Douglas A. Drossman, Jane Leserman, Weili Lin, Hui l_iu, Brent A. Vogt, William E. Whitehead Previous studies using fMRI in IBS reported differences in regional brain activation between IBS and healthy controls (Naliboff, 2001; Mertz, 2000) We have also reported differences in brain activation among patients with and without a history of abuse (Ringel, DDW 2002, 2003) The factors that contribute to these differences and the association of brain activation with psychosocial distress and pain reports have not been described. Aim: To assess the association of psychological factors and pain experience with brain activation of the anterior cingulate cortex [Perigenua[ (pACC) and midcingufate cortex (MCC)] dunng rectal balloon distention Methods: We studied 20 right-handed female subjects among l0 patients with IBS (5 with and 5 vathout abuse history), and 10 controls without IBS (5 with and 5 wuhout abuse) Psychosocial assessment included standardized measures of Global Severity Index (GSI) of SCL-90, maladaprive coping (Catastrophizing subscale of coping strategies questionnaire, Drossman Psychosom Med. 2000) and stressful life events (Leserman Am J Psychiatry 2000). fMRI images (15 T) and subjective rating of pain (on a 0-5 scale) were obtained during baseline, 15mmHg (non-painful), 50mmHg (painful), and alternating pressures of 15/50mmHg distensions. Small volume correction analysis was used to measure the activation at pACC and MCC. The association between the activation at a specific region and the subjects reports of pain, and certain psychological variables were assessed by Pearson correla tions. Results: 1) pACC activation positively correlated wuh maladaptive coping (r = 0.53, p=004), and subjective pain reports to rectal distension (r=0.48, p=0.05); 2) More stressful life events (in the past 6 months) was positively correlated with htgber MCC activation (r = 052, p = 0 0 3 ) There was no correlation of the brain activation with the GS1 of SCL-90. Conclusions: This study provides novel evidence for an association between cingulate brain activation, an area associated with cemra[ pain modulation, psychosocial distress and pain reporting. This may explain the clinical association of more severe pain among patients with psychosocial distress
Succeeded patients Failed I)~llmts
Pre-
endocinch Postendocinch
Pre-
Total reflux
Acid reflux
Acid esposure
71(519t) 32(23-
41(1870) 19(11.
9.3%(4,1%- 58%(42%20.6%) 75%) 4`9%(2,3%- 46%(26%-
60(41-
35(26- 17.9%(6.5%- 58%(11%-
61)*
45)*
9.8%)
Proximal symptom extence score
Pressure and High Frequency IntraluminalUhrasonography (HFIUS) Morphology of Nissen Fundoplication (FP) Sunil Y. joseph, Qing Zhang, Ikuo Hirano, Raymond Joehl, James Brasseur, Peter J Kahrilas
7(2.5`9.5)
65%)
endocinch 89) 65) 359%} 86%) Post95(39- 27(15- 11,8%(1.8%- 56%(15% endocinch 117} 68) 16,9%) 83%) 'valuesare: media(25%-75%). * p<0.05 vs pre-endocinch, paired t lest.
747
9(4,5-15)
12[6-19) 8(3-18}
749
Aim: To correlate .the pressure and HFIU5 characteristics of PP in relation to surgically phced markers. Methods: 8 GERD patients undergoing FP had metal markers placed on FP sutures (washers), at the apex of the hiatus (clip), at the hiatal repair (washer), and an endoscopic clip placed at the SCJ. Subjects were studied 16+/-6 months post FP with HF1US(20 MHz probe) followed by fluoroscopy with concurrent manometry. The manometer had 8 recording sites at the same axial level dispersed radially. Axial level 0 was the midpoint of the respiratory inversion zone (RIZ). The EGJ was defined by HFIUS as the most distal locus at which a circumlerential circular muscle layer was imaged. Results: 6 of the 8 patients had intact FP, 1 had a slipped Nissen and paraesophageal hernia and 1 had a disrupted FP. Analysis was performed on the 6 with intact FP. EGJ location (+ 1 lmm) correlated well w.th the SCJ (+8ram) (r= .97) and the median position of the RIZ correlated well with the apex of the hiatus (r = .99) In the patients in whom all surgical markers were imaged, mean FP washer separation was 6.3 mm whereas the FP length by HF1US was 33 mm such that it aligned with the proximal washer and extended 25 mm distal to the 2nd. Maximal 5GJ pressure was 22mmHg and was located 3ram (r 4-14) distal to the EGJ but closely correlated to the midpoint between the apex of the diaphragm and the level of the crural repair (r = .99). FP disruption was evident by obviously mislocated fundoplication washers SlippedNissen was demonstrated by HFIUS localization of the EGJ above the PP. Paraesophagea[hernia was characterized by a highly asymmetric esophageal pressure. Conclusions: 1) HFIUS can reliably locate the anatomical EGJ, position and length of fundoptication, FP disruption, and slipped Nissen, 2) HFIUS may be a useful clinical tool in evaluating the integrity of FP.
Clinical response after Stretta procedure for GERD reflects improvement in esophageal acid exposure George Triadafilopoulos Background: Radiofrequency energy delivery (Stretta procedure) has been shown, in open label and sham controlled studies, to be safe and effective for the management of GERD. One criticism, however, has been the theory that the primary mechanism of action of Stretta is ablative denervation of the esophageal body, rather than a reduction in esophageal acid exposure because of augmentation of the anti-reflux barrier. To resolve this question, we sought to determine if there was a positive correlation between the improvement in GERD outcomes and esophageal acid exposure. Methods: The Stretta Open Label Trial database represents 118 patients treated in 1999 at 14 U.S. institutions. While the results of this trial have been previously reported, we performed subgroup analyses based on patient outcomes for GERD-HRQL (0-50), heartburn seventy (0-5), daily PPI use (yes/no), and satisfaction (0-5) A response for each subgroup was defined as GERD-HRQL less than 10, heartburn less than 1, no daily PPl use, and satisfaction more than 4. Baseline (before Stretta) and follow-up (6 months after Stretta) esophageal acid exposure (proximal and distal) were then compared for each responder and non-responder group. Results: All responder subgroups demonstrated significant improvement in both proximal and distal acid exposure. Nonresponder subgroups, however, either did not demonstrate improvement in proximal or distal acid exposure or had a sigmficantly smaller improvement versus the responder subgroup. For responder groups, symptom improvement correlated with improvement in acid exposure, while in non-responder groups there was no correlation Proximal acid exposure was more likely to be improved and more likely to be normalized than distal acid exposure for the responder group, suggesting that this componem of reflux contributes perhaps more
A-97
AGA
Abstracts
significantly to GERD symptoms in this cohort. The relationship between % time with pH less than 4 and responder status by GERD-HRQL is shown in Table. Conclusion: Clinical responders to the Stretta procedure, as defined by the subgroup parameters, have significant improvements and normalization in both proximal and distal esophageal acid exposure, while non-responders either have no improvement or less improvement. This data refutes the theory that Stretta relieves symptoms and improves patient satisfaction by desensitizing the esophageal body.
Clinical and fun~onal ouCon~ ~
R#oml
falinre rate after 4/24 months LES preoperative (mmHg) after 4 months afinr 2 yam DeMaester Score preop. erathte after 4 mot~kt u#er 2 years Dyuphagia preoperat~a (number of pa6ents) alter 4 months after 2 yea~
Dintal medlm % time with pH len than 4 bofore and alter StreUa Relponder Non.relpondw
10.4 10.0
4.3 7.7
750 Effect of Radiofrequency Ablation on Gastric Dysrhythmias and Gastric Emptying in Patients with Gastroesophageal Reflux Disease (GERD) and Functional Dyspepsia Mark Noar, Lihua Xu, Kenneth L. Koch
in 200 patients wi~ GERD
NisslmToup~ IPvalue Dyumo-
my
11/15
4/8
ns
10/15
11/14
ns
11.3
13,6
ns
8.9
10,1
ns
16.6 14.7 45,4
16.9 13.5 39.1
ns
16,5
13.4
ns
14,0
11.5
ns
4t.6
43,9
<0,01 <0.05 ns
12.5 19.1 14
4,8 12.8 11
<0.05 ns ns
11.2 16.7 16
8.0 20.7 22
ns ns --0.03
24 4
7 3
<0.01 ns
20 9
10 4
<0.05 ns
752
Gastric neuromuscular dysfunction has a role in GERD and in functional dyspepsia symptoms. Gastric dysrhythmias have been recorded in patients with dyspepsia who also have GERD. Radiofrequency ablation (RFA) is used to treat GERD and may work by ablating vagal sensory neural pathways. AIMS: To determine the effect of RFA treatmem of the lower esophageal sphincter/cardia region on t) Gastric myoelectrical activity; 2) Gastric emptying (GE); and 3) Gastric capacity in patients with GERD plus dyspepsia (GERD + ). METHODS: 43 patients (31 women and 12 men, ages 19-78 yr.) referred to a community-based GI practice for refractory GERD underwent endoscopy and electrogastrogram (EGG) with water load tests (WLT) and GE prior to RFA (Stretta procedure). Endoscopies showed Grade 1 esophagitis or normal mucosa. EGG with water load test was performed in standard fashion and diagnoses (bradygastria, tachygastria, mixed dysrhythmia or normal) were made on the basis of EGG rhythm strips and computer analysis. GE tests used isotope-labeled eggs. RESULTS: Stretta procedure was performed successfully in each of the 43 patients. Pre-RFA EGG diagnoses were: tachygastria in 47%, bradygnstria in 11%, mixed dysrhythmia in 14% and normal in (12/43) 28%. The EGG with WLT was repeated 7.3 months after the RFA treatment. Post-RFA diagnoses were: tachygastria in 28%, bradygastria in 4%, mixed dysrhythmia in 14% and normal in (23/43) 53% (P<0.03). Overall, 35% (11/31) of the patients with baseline gastric dysrhythmias convened to normal EGG patterns after RFA. 8/20 (43%) of tachygastriasconverted to normal 3 cpm rhythm. These patients had significant improvement in GE (47% to 85% emptied, P<0.01), compared with patient normal EGG (67% to 82%, P=0.16). Normal baseline EGGs were found in 12 patients. Pre-procedure WLT volume was 444 +/- ml and post-procedure volume was 389 +/- ml (P
Lower Esophageal Sphincter Function After Endoscopic EVOH Polymer Injection for GERD Treatment: 1 Year Results Hubert Louis, Winfried Voderholzer, Olivier Le Moine, David Silverman, Jacques Deviere Introduction: Implantation of ethylene-vinyl-alcohol polymer (EVOH) in the lower esophageal sphincter (LES) improves symptoms in patients with gastroesophageal reflux disease (GERD). Aims & Methods : To analyze the effect of EVOH injection on the LES function, 13 patients (4 male, 9 female) with GERD (GERD symptoms controlled with PPI, 0%pH < 4 > 5) underwent esophageal manometry 30 rnin before and 90 mill after a semiliquid meal, before and 1 month after EVOH implamation. Follow-up was obtained at 6 and 12 momhs for 7 patients. Twenty-four hour ambulatory pH-metry was performed before and 6 months after implantation. Results: (Table: median (range), *p
%time pH <4
751
Reflux eplsodez/24h GERD HQRL score N patient=
A Prospective Randomized Trial to Study the Effect of Esophageal Motility on Long-Term Results of Nissen and Toupet Fundoplication for Gastroesophageal Reflux Disease. Results of a 2 Years Follow-Up Christians Fibbe, Jutta Keller, Alice Emmermann, Carsten Zornig, Peter Layer
Pre-trea'mnm~
1 month
6 months
12 months
10,4 (7-22)
16.8 (6-32)"
11.1 (8-23)
14,4 (6-29)
.O (0-1)
2.8 (0-18)* .0 (0-9) 3 (2-5)
1.7 (0-7)*
3,2 (0-7)*
3 (0-7) 3 (2-4)
12.5 163 21 (5-27) 13
8,5 (0-28)* 13
1 (0-3)
1 (04)
3 (2-5)
3.3 (2-4)
7.1 77 11.5 (0-28)"
3 (0-22)*
7
7
753
Background: it is uncertain if amirs flux surgery can normalize esophageal motility, or if adjusting surgical techniques to underlying motor disturbances (tailored concept) improves clinical outcome. Aims: to assess the results which can be achieved by tailoring the antireflux procedure to the esophageal motor function in patients with GERD. Methods: Between may 1999 and may 2000, 200 patients (121 male, 79 female; median age 56 (range 20-80) years) with long-term medical treatment for GERD were randomized prospectively to either a partial wrap Toupet (T;n = 100) or a 360 degree Nissen fundoplication (N;n = 100) ignoring preoperative esophageal motility.In each treatment group an equal number of patients had normal or impaired esophageal motility. All underwent esophageal function testing (upper GI endoscopy, esophageal manometry, 24['1pH-monitoring and clinical assessment) preoperatively and as a postoperative follow-up 4 and 24 months later. Results: Dysphagia was more common in the early follow up after N especially in the normal motility group, a difference which disappeared vclth time. There was no difference in the cumulative relapse rate (30% N vs 22% T). The increase in reflux recurrence after 2 years corresponded to a decrease in LES resting tone over the time independem of esophageal motor function or the procedure performed. Despite reflux control postop, esophageal motility remained unchanged in 85%. Conclusions: N and T equally well and durably control GERD independent of esophageal motility, although the efficacy of reflux comrol seems to diminish over the time. Only in the early postoperative course fewer symptoms occur in those having a T. Both procedures do not normalize esophageal dysmotility. Therefore esophageal dysmotility may not require tailoring of surgical management.
AGA Abstracts
Niuen and Toupet f u n d o ~
Niuen Toupet pvalue Botil-
Aggressive Surgical Treatment for Recurrent Hepatocellular Carcinoma Akira Kobayashi, Shinichi Miyagawa, Akimasa Matsnshita, Takenari Nakata, Kazuhiko Nomura, Terumasa Noike, Shiro Miwa, Kazuhiro Hanazaki, Kan Nakagawa Background: Advancement in perioperative management and operative techniques has improved the results of liver resection for HCC dramatically. However, the long-term prognosis remains unsatisfactory because of a high incidence of recurrence. Although several studies have advocated repeat liver resection as the most effective treatment modality for patients with intrahepatic recurrent HCC, obviously no conclusion can be drawn about the survival benefit of repeat bepatectomy, because the number of patients was small. Aim: The aim of this study is to evaluate the outcome of 80 repeat hepatectomies and to clarify the role of this treatment strategy. Patients and Methods: Between January 1990 and December 2001, we have performed 404 curative hepatectomies: 324 initial and 80 repeat liver resections, on 337 HCC patients. The median follow-up period after initial hepatectomy was 36 momhs (mean, 44 months; range, 0.4-137 months), and recurrence was confirmed in 214 patients (66%). The liver was the only site in 179 patients. Repeat (second) liver resection was performed in a total of 60 patients: 52 who underwent the initial hepatectomy at our hospital and 8 who underwent their initial liver resection at other hospitals. Results: The mean and median blood loss in the 60 patients who underwent second hepatectomy was 584 ml and 450 ml, respectively (range, 46-2850 ml). Only 2 patients (3%) required red blood ceil transfusion perioperatively. There were no operative or hospital deaths. The mean and median follow-up periods after repeat hepatic resection were 40 months and 39 months, respectively (range, 1-110). The 1-, 3-, and 5-year survival rates after the second hepatic resection were 96.7%, 73.9%, and 52.9, respectively. Recurrent HCC after the second hepatectomy was found in 40 patients. Of them, 13 patients and another 5 patients who had their first and second liver resections at other institutions underwent a third liver resection. The mean and median blood loss during the third liver resection was 746 ml and 475 ml, respectively (range, 60-2300 ml). There were no in-hospital deaths. Recurrence in the liver remnant after the third operation was confirmed in 11 patients, and fourth operation was performed in 2 of them. These 2 patients are currently alive, 74 months and 105 months, respectively after their initial hepatectomy. Conclusion: Repeat hepatic resection is a safe and effective treatment modality for patients with intrahepatic recurrence of HCC.
A-98