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pH)
2440
Abstracts
AJG – Vol. 95, No. 9, 2000
balloon inflation technique coupled with monitoring of airways by bronchoscopy, this potential complication can be avoided.
100 Prospective comparison of helical CT (HCT), endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration (FNA) for preoperative esophageal cancer (EC) staging Vazquez-Sequeiros E, MD, Clain JE, FACG, Norton I, MD, Rajan E, MD, Romero Y, MD, Salomao D, MD, Wang KK, MD, Wiersema MJ, FACG. Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, MN. Background: Detection of lymph node (LN) metastases in EC may influence treatment decisions. To date, a prospective comparison of HCT, EUS and FNA for locoregional staging of EC has not been performed. Purpose: 1) To prospectively compare the utility of HCT, EUS and FNA for preoperative EC staging. 2) Determine the impact of EUS and FNA on treatment decision of EC patients. Methods: From 1/2000 to 6/2000, 30 consecutive patients with histologically proven EC (considered for surgical resection) underwent preoperative staging with HCT, EUS and FNA. EUS LN staging was determined prior to FNA by conventional EUS criteria. Final diagnosis was made based on surgical results or FNA malignant cytology. Results: Final LN staging is complete in 25 patients: mean age 66 years (range 39 – 82), male/female 16/9, adeno/squamous cell carcinoma 22/3. Based on EUS and FNA. 80% of patients (20 of 25) underwent adjuvant therapy prior to operative intervention. In the 5 patients who directly underwent surgery, EUS T stage was correct in all 5 cases. EUS exams identified 168 LN (median number 4, range 1–12). FNA was performed on 54 LN (median width: 6 mm, range 2–30; passes per LN: median 3, range 1–5). No complications were experienced. Global LN staging HCT EUS EUS-FNA
sensitivity
specificity
accuracy
7/22⫽32% 18/22⫽82% 20/22⫽91%
2/3⫽66% 1/3⫽33% 3/3⫽100%
9/25⫽36% 19/25⫽76% 23/25⫽92%
HCT was less sensitive and accurate than EUS and/or FNA for LN global staging (p⬍0.005).
reflux (defined as impedance-detected volume reflux without accompanying pH decrease to below 4.0) and for delta pH 1 and delta pH 2 with pH ⬎ 4.0. Results: 67 nonacid reflux episodes detected; 48 had no delta (up or down), 19 had a delta pH ⬎1, 7 had a delta pH ⬎2. There was no association of symptoms with delta pH ⬎1, ⬎2, or absent delta (see table). delta >1 symptom present symptom absent
8 11
delta >2 3 4 p ⫽ ns
101 Delta pH (1 or 2 units) is not associated with symptoms in nonacid reflux: A study using combined multichannel intraluminal impedance and pH (MII/pH) MF Vela, MD, R Srinivasan, PO Katz, MD, FACG, DO Castell, MD, FACG. Graduate Hospital, Philadelphia, PA. Introduction: Reflux of volume without a concomitant change in pH to below 4.0, so called nonacid reflux, can be detected by MII/pH. We have previously shown that nonacid reflux can cause symptoms. (Gastroenterology 1999:118, A489). It has been suggested that drops of 1 or more pH units can cause symptoms even without a pH below 4.0 (i.e. delta pH). Aim: Assess the importance of delta pH of 1 or 2 units in perception of reflux symptoms. Methods: Male patients (mean age⫽35) with frequent heartburn on no therapy underwent a 4 hour study of MII/pH (Sandhill Scientific, Inc.). First two hours in right lateral decubitus position after a standardized refluxogenic meal (60% fat); second two hours sitting upright after a second refluxogenic meal. Heartburn, regurgitation, acid taste and chest pain, recorded real-time on the tracing. Impedance and pH analyzed for nonacid
28 20
Conclusions: These data do not support the use of delta pH as an indicator of symptom correlation in nonacid reflux, nor pH rise as indication of nonacid gastroesophageal reflux. 102 Esophageal function in normal subjects and patients with either scleroderma (SCL) or ineffective esophageal motility (IEM) assessed through multichannel intraluminal impedance (MII) MF Vela, MD, R Srinivasan, PO Katz, MD, FACG, DO Castell, MD, FACG. Graduate Hospital, Philadelphia, PA. Introduction: Low amplitude or absent peristaltic waves are seen in both IEM and SCL. We have previously shown that MII allows accurate measurement of bolus transport time (BTT) and contraction wave velocity (CWV) along the entire esophagus (Gastroenterology 1999;118:A245). Aim: To assess esophageal function in normal subjects (NL) and patients with IEM and SCL through measurement of BTT and CWV determined by MII. Methods: Five NL (normal manometry), 5 IEM patients (30% or more ineffective peristaltic waves) and 4 SCL patients with esophageal involvement underwent MII (Sandhill Sci, Inc) with six 2-cm recording segments located 2, 4, 6, 8, 14, and 20 cm above the LES. Each subject given 15 swallows (5 ⫻ 5ml water, 5 ⫻ 5ml applesauce, 5 ⫻ 15mm spherical ionic marshmallows). Two parameters measured: 1) BTT: time (sec) for bolus to travel through the entire esophagus and, 2) CWV: speed of contraction wave from proximal to distal measuring segment. Results: Shown in table below. Table 1 mean and s.d.
Conclusions: 1) EUS and FNA are more sensitive and accurate than HCT for preoperative LN staging of EC. 2) FNA appears to improve EUS LN staging in EC patients. 3) EUS and FNA modify treatment decisions in the majority of EC.
no delta
normals BTT water BTT apple BTT marsh CWV water CWV apple CWV marsh
IEM
comparisons SCL
5.6 ⫾ 1.2 8.0 ⫾ 1.4 7.8 ⫾ 1.1 7.8 ⫾ 1.5 8.6 ⫾ 1.7 9.1 ⫾ 1.2 7.5 ⫾ 3.0 10.3 ⫾ 2.6 * 3.9 ⫾ 1.1 2.0 ⫾ 0.5 1.8 ⫾ 0.2 2.5 ⫾ 0.5 2.2 ⫾ 0.5 1.9 ⫾ 0.2 2.6 ⫾ 0.8 2.0 ⫾ 0.4 *
NL vs. IEM
NL vs. SCL
IEM vs. SCL
p ⬍ 0.001 p ⫽ ns p ⫽ 0.0013 p ⬍ 0.001 p ⬍ 0.01 p ⫽ 0.0024
p ⬍ 0.001 p ⬍ 0.05 * p ⬍ 0.001 p ⬍ 0.001 *
p ⫽ ns p ⫽ ns * p ⫽ ns p ⫽ ns *
* not calculable: 0 marshmallows cleared.
Conclusion: Swallowing function studied through MII enables differentiation between normal subjects and patients with IEM and scleroderma. This technique may become a useful tool in evaluation of esophageal function without use of radiation. 103 Screening for Barrett’s esophagus with an ultrathin endoscope in a population with chronic reflux: A cost effectiveness analysis Michael B. Wallace, P.J. Nietert, M.D. Silverstein, Mahesh S. Mokhashi, Tammy F. Glenn, Robert H. Hawes. Medical University of South Carolina, Charleston, South Carolina, United States. Purpose: Persons with gastroesophageal reflux disease (GERD) are at increased risk of developing Barrett’s Esophagus (BE) and adenocarcinoma. Screening with standard endoscopy is expensive and unproven. A
Abstracts
AJG – Vol. 95, No. 9, 2000
balloon inflation technique coupled with monitoring of airways by bronchoscopy, this potential complication can be avoided.
100 Prospective comparison of helical CT (HCT), endoscopic ultrasound (EUS) and EUS-guided fine needle aspiration (FNA) for preoperative esophageal cancer (EC) staging Vazquez-Sequeiros E, MD, Clain JE, FACG, Norton I, MD, Rajan E, MD, Romero Y, MD, Salomao D, MD, Wang KK, MD, Wiersema MJ, FACG. Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, MN. Background: Detection of lymph node (LN) metastases in EC may influence treatment decisions. To date, a prospective comparison of HCT, EUS and FNA for locoregional staging of EC has not been performed. Purpose: 1) To prospectively compare the utility of HCT, EUS and FNA for preoperative EC staging. 2) Determine the impact of EUS and FNA on treatment decision of EC patients. Methods: From 1/2000 to 6/2000, 30 consecutive patients with histologically proven EC (considered for surgical resection) underwent preoperative staging with HCT, EUS and FNA. EUS LN staging was determined prior to FNA by conventional EUS criteria. Final diagnosis was made based on surgical results or FNA malignant cytology. Results: Final LN staging is complete in 25 patients: mean age 66 years (range 39 – 82), male/female 16/9, adeno/squamous cell carcinoma 22/3. Based on EUS and FNA. 80% of patients (20 of 25) underwent adjuvant therapy prior to operative intervention. In the 5 patients who directly underwent surgery, EUS T stage was correct in all 5 cases. EUS exams identified 168 LN (median number 4, range 1–12). FNA was performed on 54 LN (median width: 6 mm, range 2–30; passes per LN: median 3, range 1–5). No complications were experienced. Global LN staging HCT EUS EUS-FNA
sensitivity
specificity
accuracy
7/22⫽32% 18/22⫽82% 20/22⫽91%
2/3⫽66% 1/3⫽33% 3/3⫽100%
9/25⫽36% 19/25⫽76% 23/25⫽92%
HCT was less sensitive and accurate than EUS and/or FNA for LN global staging (p⬍0.005).
reflux (defined as impedance-detected volume reflux without accompanying pH decrease to below 4.0) and for delta pH 1 and delta pH 2 with pH ⬎ 4.0. Results: 67 nonacid reflux episodes detected; 48 had no delta (up or down), 19 had a delta pH ⬎1, 7 had a delta pH ⬎2. There was no association of symptoms with delta pH ⬎1, ⬎2, or absent delta (see table). delta >1 symptom present symptom absent
8 11
delta >2 3 4 p ⫽ ns
101 Delta pH (1 or 2 units) is not associated with symptoms in nonacid reflux: A study using combined multichannel intraluminal impedance and pH (MII/pH) MF Vela, MD, R Srinivasan, PO Katz, MD, FACG, DO Castell, MD, FACG. Graduate Hospital, Philadelphia, PA. Introduction: Reflux of volume without a concomitant change in pH to below 4.0, so called nonacid reflux, can be detected by MII/pH. We have previously shown that nonacid reflux can cause symptoms. (Gastroenterology 1999:118, A489). It has been suggested that drops of 1 or more pH units can cause symptoms even without a pH below 4.0 (i.e. delta pH). Aim: Assess the importance of delta pH of 1 or 2 units in perception of reflux symptoms. Methods: Male patients (mean age⫽35) with frequent heartburn on no therapy underwent a 4 hour study of MII/pH (Sandhill Scientific, Inc.). First two hours in right lateral decubitus position after a standardized refluxogenic meal (60% fat); second two hours sitting upright after a second refluxogenic meal. Heartburn, regurgitation, acid taste and chest pain, recorded real-time on the tracing. Impedance and pH analyzed for nonacid
28 20
Conclusions: These data do not support the use of delta pH as an indicator of symptom correlation in nonacid reflux, nor pH rise as indication of nonacid gastroesophageal reflux. 102 Esophageal function in normal subjects and patients with either scleroderma (SCL) or ineffective esophageal motility (IEM) assessed through multichannel intraluminal impedance (MII) MF Vela, MD, R Srinivasan, PO Katz, MD, FACG, DO Castell, MD, FACG. Graduate Hospital, Philadelphia, PA. Introduction: Low amplitude or absent peristaltic waves are seen in both IEM and SCL. We have previously shown that MII allows accurate measurement of bolus transport time (BTT) and contraction wave velocity (CWV) along the entire esophagus (Gastroenterology 1999;118:A245). Aim: To assess esophageal function in normal subjects (NL) and patients with IEM and SCL through measurement of BTT and CWV determined by MII. Methods: Five NL (normal manometry), 5 IEM patients (30% or more ineffective peristaltic waves) and 4 SCL patients with esophageal involvement underwent MII (Sandhill Sci, Inc) with six 2-cm recording segments located 2, 4, 6, 8, 14, and 20 cm above the LES. Each subject given 15 swallows (5 ⫻ 5ml water, 5 ⫻ 5ml applesauce, 5 ⫻ 15mm spherical ionic marshmallows). Two parameters measured: 1) BTT: time (sec) for bolus to travel through the entire esophagus and, 2) CWV: speed of contraction wave from proximal to distal measuring segment. Results: Shown in table below. Table 1 mean and s.d.
Conclusions: 1) EUS and FNA are more sensitive and accurate than HCT for preoperative LN staging of EC. 2) FNA appears to improve EUS LN staging in EC patients. 3) EUS and FNA modify treatment decisions in the majority of EC.
no delta
normals BTT water BTT apple BTT marsh CWV water CWV apple CWV marsh
IEM
comparisons SCL
5.6 ⫾ 1.2 8.0 ⫾ 1.4 7.8 ⫾ 1.1 7.8 ⫾ 1.5 8.6 ⫾ 1.7 9.1 ⫾ 1.2 7.5 ⫾ 3.0 10.3 ⫾ 2.6 * 3.9 ⫾ 1.1 2.0 ⫾ 0.5 1.8 ⫾ 0.2 2.5 ⫾ 0.5 2.2 ⫾ 0.5 1.9 ⫾ 0.2 2.6 ⫾ 0.8 2.0 ⫾ 0.4 *
NL vs. IEM
NL vs. SCL
IEM vs. SCL
p ⬍ 0.001 p ⫽ ns p ⫽ 0.0013 p ⬍ 0.001 p ⬍ 0.01 p ⫽ 0.0024
p ⬍ 0.001 p ⬍ 0.05 * p ⬍ 0.001 p ⬍ 0.001 *
p ⫽ ns p ⫽ ns * p ⫽ ns p ⫽ ns *
* not calculable: 0 marshmallows cleared.
Conclusion: Swallowing function studied through MII enables differentiation between normal subjects and patients with IEM and scleroderma. This technique may become a useful tool in evaluation of esophageal function without use of radiation. 103 Screening for Barrett’s esophagus with an ultrathin endoscope in a population with chronic reflux: A cost effectiveness analysis Michael B. Wallace, P.J. Nietert, M.D. Silverstein, Mahesh S. Mokhashi, Tammy F. Glenn, Robert H. Hawes. Medical University of South Carolina, Charleston, South Carolina, United States. Purpose: Persons with gastroesophageal reflux disease (GERD) are at increased risk of developing Barrett’s Esophagus (BE) and adenocarcinoma. Screening with standard endoscopy is expensive and unproven. A