- Email: [email protected]
Dental Erosion in Patients Carrying of Gastroesophageal Reflux Esophagitis
Abstracts
M1326 Predictors and Quantitative Assessment of Incomplete Response After Radiofrequency Ablation for Dysplastic Barrett’s Esophagus: Analysis of Randomized Sham-Controlled Clinical Trial (The AIM Dysplasia Trial) Charles J. Lightdale, Bergein F. Overholt, Kenneth K. Wang, Hiroshi Mashimo, Virender K. Sharma, David E. Fleischer, Joseph Galanko, Nicholas J. Shaheen, Prateek Sharma Background: Radiofrequency ablation (RFA) has been shown to completely eradicate dysplastic intestinal metaplasia (IM) in most patients, yet residual IM may persist in some. Aims: The primary endpoint for RFA therapy is complete response-IM (CR-IM, no histological evidence of IM). We sought to describe pt characteristics related to incomplete response-IM (IR-IM, any residual IM). We also assessed dysplasia grade, and extent/location of any residual IM. Methods: We enrolled 127 pts with dysplastic BE (63 HGD, 64 LGD) in a multi-center trial of RFA. Pts were randomized 2:1 (RFA vs. sham) then biopsied q 3 or 6 mo, with centralized path review. RFA was performed until CR-IM or max 4 sessions. Results: 52 pts (35 RFA, 17 sham) have evaluable 12 mo histology. This sub-analysis of the RF group compares CR-IM to IR-IM at 12 mo. The groups had similar hiatal hernia size. IR-IM had a longer pre-treatment period with dysplasia (p ! 0.05). They were also older and had higher BMI, more years with BE, longer BE cm, and more multi-focal dysplasia, but given the small sample size of IR-IM, none of these was significant (table). All IR-IM pts had downgrading of dysplasia. For the 3 IR-IM pts with baseline HGD, the worst grade of residual IM was non-dysplastic (1), indefinite (1), or LGD (1). For the 3 IR-IM pts with baseline LGD, all were downgraded to non-dysplastic IM. Of the 6 IR-IM pts at 12 mo, 4 had a single-level IM focus, while 2 had multi-level disease. Five of 6 IR-IM pts had IM only within 1 cm of the top of gastric folds (TGF), while 1 pt had more proximal IM (4-5 cm from the TGF). One IR-IM pt had persistent GERD esophagitis, 1 had ibuprofen-induced ulceration, and 1 had a baseline stricture preventing focal balloon contact. Conclusions: All IR-IM had downgrading of dysplasia and substantial reduction of IM burden. IR-IM pts had a longer pre-treatment period with dysplasia than CR-IM. IR-IM also had insig increases in age, baseline BE length, BMI and % multi-focal. Follow-up RFA is planned for these pts, with the goal to eliminate residual disease.
Patients (n, %) Male (n, %) Age years (median, IQR) BMI (median, IQR) Years with BE / dysplasia (median) Baseline Prague (CM) median Baseline multifocal dysplasia (n, %) Baseline HGD (n, %) RFA procedures (median) 12 mo fragments (n) 12 mo fragments with IM (n, % total)
CR-IM
IR-IM
29 (83%) 24 (83%) 64 (59-69) 26.5 (25-31) 3.4 / 0.6 1.5 / 4.0 21 (72%) 9 (31%) 4 806 0 (0%)
6 (17%) 5 (83%) 70.5 (64-74) 28.9 (27-32) ) 6.0 / 2.2 4.5 / 6.5 6 (100%) 3 (50%) 4 266 25 (9.3%)
results obtained indicates that the volunteers that had ED showed some degree of GERE, higher age band and lower level of schooling.
M1328 Prevalence of Complicated Gastroesophageal Reflux Disease and Barrett’s Esophagus Among Racial Groups in a Multi-Center Consortium Amy Wang, Nora Mattek, David A. Lieberman, Glenn M. Eisen Background and Aims: Current belief is that Caucasians are more likely to develop complicated gastroesophageal reflux disease (GERD) and/or Barrett’s esophagus (BE), although evidence to support this ethnic predilection is lacking. The aim of this study was to estimate the frequency of complicated GERD and suspected BE among various racial groups using the Clinical Outcomes Research Initiative (CORI) database. Methods: The CORI database was searched between January 2000 and December 2005 to identify unique adult patients who underwent upper endoscopy for any indication, as well as those undergoing endoscopy for indications of interest: dyspepsia, reflux symptoms, and BE screening. Procedures for BE surveillance were excluded. Racial groups were identified as white non-Hispanic (WNH), black non-Hispanic (BNH), Hispanic, and Asian/Pacific Islander (API). Chisquare analysis was used to compare categorical variables and multiple logistic regression was used to measure adjusted relative risks. Results: A total of 280,075 procedures were examined (82% WNH, 8% BNH, 8% Hispanic, 2% API). Reflux was the most frequent indication of interest for all groups except API. Hispanic subjects were most likely to have esophagitis (Hispanic 23.2% vs. WNH 19.6% vs. BNH 17.4% vs. API 11.2%, p-value!0.0001). WNH subjects were most likely to have suspected BE (WNH 5.0% vs. Hispanic 2.9% vs. API 1.8% vs. BNH 1.5%, p-value!0.0001) and esophageal stricture (WNH 10.7% vs. BNH 6.2% vs. Hispanic 3.1% vs. API 1.8%, pvalue!0.0001). Examining endoscopies of specific indications of interest revealed similar trends for findings of esophagitis and esophageal stricture. When BE screening was an indication, API were most likely to have suspected BE (API 20.4% vs. WNH 18.5% vs. Hispanic 16.8% vs. BNH 9.2%, p-value Z 0.02). Among reflux/BE screening procedures adjusted for age and gender, Hispanics were most likely to have esophagitis (Hispanic OR Z 1.4, 95% CI: 1.33-1.48; WNH OR Z 1.0; BNH OR Z 0.77, 95% CI: 0.72-0.82; API OR Z 0.61, 95% CI: 0.53-0.71, p-value!0.0001), and WNH were most likely to have suspected BE (WNH OR Z 1.00; Hispanic OR Z 0.75, 95% CI: 0.67-0.83; API OR Z 0.48, 95% CI: 0.36-0.64; BNH OR Z 0.44, 95% CI: 0.37-0.51, p-value!0.0001). The number needed to endoscope to identify one case of suspected BE was lowest in WNH males older than 50 years of age who undergo upper endoscopy for reflux symptoms or BE screening. Conclusions: While suspected BE and esophageal stricture are more likely to be detected in WNH, esophagitis appears to occur more frequently in Hispanics. These predilections may help further define the role of upper endoscopy in the management of GERD among racial groups.
)p ! 0.05
M1327 Dental Erosion in Patients Carrying of Gastroesophageal Reflux Esophagitis Marilene B. Alves, Kiyoshi Hashiba, Eduardo A. Andre, Carlos A. Cappellanes, Daniel S. Vilas Boas, Esther G. Birman Background: The gastroesophageal reflux esophagitis (GERE) has a chronic distinguishing mark and epidemiological studies shows that 11% of the Brazilian population relate symptoms compatible with the reflux ones at the very least one time per week. The reduction of oral pH caused by the GERE can provoke the dissolution of the hydroxiapatite leading to the dental erosion (DE) signaling one of the consequences of the action of reflux. Aim: This study evaluated the degree of DE in the individuals in relation of the degree of GERE, age band and level of schooling. Methods: Had participated of our study, individuals with ages varying between 20 and 80 years old (mean Z 46,76 14,27) of both genders with endoscopic diagnosis of GERE (GERE group, n Z 120) and individuals with ages varying between 21 and 80 years old (mean Z 39,97 13,98) of both genders with normal endoscopic examination (non-GERE group, n Z 60), after signature of the informed consent. The volunteers of this research had been submitted to an high digestive endoscopy followed by a clinical oral examination. The GERE when present, was classified according to Savary-Miller scale and the DE when present, according to Eccles-Jenkins scale. The statistics analysis of the results was carried through by the Pearson’s Qui-square test. Results: The results have indicated that the GERE is a significant factor for the appearing of DE (p Z 0,02). All of volunteers DE carriers had some degree of esophagitis. The age band, as well, is a significant factor for the DE appearing (p Z 0,02): the higher the age band, the higher the degree of DE. The level of schooling is a highly significant factor for DE appearing (p Z 0,001): the lower the level of schooling, the higher the degree of DE. The gender isn’t a significant factor for DE appearing in comparison of the non-GERE group (p Z 0,18). Conclusions: The
AB182 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
M1329 Long Term Prognosis of ESD for the Superficial Esophageal Squamous Cell Carcinoma Tsuneo Oyama, Yoko Kitamura, Kinichi Hotta Introduction: Lymph node metastasis (LNM) of esophageal squamous cell carcinoma (SCC) has been reported to correlate closely with the invasion depth and lymph duct involvement. When the invasion depth was intraepitheliam (m1) or proper mucosa (m2), the LNM has been reported 0 %. When SCC contacted with muscularis mucosa (m3) or invaded to submucosal layer 200 micrometer or less (sm1), the LNM is 9 to 20%. Therefore, the Japanese Esophageal Association decided the standard and expanding indication of esophageal EMR as the lesions those invasion depth is m1 or m2 and m3 or sm1, respectively. En bloc resection is necessary for the precise pathological examination. Therefore, endoscopic submucosal dissection (ESD) was developed. However, the long term prognosis after esophageal ESD is obscure. Aims & Methods: The aim of this study is to analyze the outcome of esophageal SCC treated by ESD and clarify the long term prognosis after esophageal ESD. 177 SCC in 158 patients were treated by ESD from Jan. 2000 to Oct. 2006 at Saku Central Hospital. The median age and observation period was 68 (44-86) and 32 months (4-90). The patients were divided into three groups due to the invasion depth; m1-2, m3-sm1 and sm2-3. M1 or m2 patients were followed up by Endoscopy and CT scan once a year. M3 or deep were recommended to be treated by esophagectomy with lymph node dissection or chemo radio therapy (CRT). If the patients refused the additional treatment, they were followed up by endoscopy and CT scan, twice a year. 176 of 177 patients were followed up in this study. Result of ESD1. Complete resection : 94%. 2. Median tumor and resected size was 24 mm (3 - 65) and 38 mm (12-73).3. Complications: Perforation 0%, Delayed perforation 0.6%, Mediastinal emphysema 4.5% (8/177) and Stricture 7.3% (13/177) . 4. Local recurrence was 0%. Prognosis of ESD1. M1 or m2 group, n Z 111. The median age and observation period was 68 (44-82) and 32 months (4-90). 9 patients died of other diseases. 2. M3 or sm1 group, n Z 39The median age and observation period was 67 (50-82) and 32
www.giejournal.org
M1326 Predictors and Quantitative Assessment of Incomplete Response After Radiofrequency Ablation for Dysplastic Barrett’s Esophagus: Analysis of Randomized Sham-Controlled Clinical Trial (The AIM Dysplasia Trial) Charles J. Lightdale, Bergein F. Overholt, Kenneth K. Wang, Hiroshi Mashimo, Virender K. Sharma, David E. Fleischer, Joseph Galanko, Nicholas J. Shaheen, Prateek Sharma Background: Radiofrequency ablation (RFA) has been shown to completely eradicate dysplastic intestinal metaplasia (IM) in most patients, yet residual IM may persist in some. Aims: The primary endpoint for RFA therapy is complete response-IM (CR-IM, no histological evidence of IM). We sought to describe pt characteristics related to incomplete response-IM (IR-IM, any residual IM). We also assessed dysplasia grade, and extent/location of any residual IM. Methods: We enrolled 127 pts with dysplastic BE (63 HGD, 64 LGD) in a multi-center trial of RFA. Pts were randomized 2:1 (RFA vs. sham) then biopsied q 3 or 6 mo, with centralized path review. RFA was performed until CR-IM or max 4 sessions. Results: 52 pts (35 RFA, 17 sham) have evaluable 12 mo histology. This sub-analysis of the RF group compares CR-IM to IR-IM at 12 mo. The groups had similar hiatal hernia size. IR-IM had a longer pre-treatment period with dysplasia (p ! 0.05). They were also older and had higher BMI, more years with BE, longer BE cm, and more multi-focal dysplasia, but given the small sample size of IR-IM, none of these was significant (table). All IR-IM pts had downgrading of dysplasia. For the 3 IR-IM pts with baseline HGD, the worst grade of residual IM was non-dysplastic (1), indefinite (1), or LGD (1). For the 3 IR-IM pts with baseline LGD, all were downgraded to non-dysplastic IM. Of the 6 IR-IM pts at 12 mo, 4 had a single-level IM focus, while 2 had multi-level disease. Five of 6 IR-IM pts had IM only within 1 cm of the top of gastric folds (TGF), while 1 pt had more proximal IM (4-5 cm from the TGF). One IR-IM pt had persistent GERD esophagitis, 1 had ibuprofen-induced ulceration, and 1 had a baseline stricture preventing focal balloon contact. Conclusions: All IR-IM had downgrading of dysplasia and substantial reduction of IM burden. IR-IM pts had a longer pre-treatment period with dysplasia than CR-IM. IR-IM also had insig increases in age, baseline BE length, BMI and % multi-focal. Follow-up RFA is planned for these pts, with the goal to eliminate residual disease.
Patients (n, %) Male (n, %) Age years (median, IQR) BMI (median, IQR) Years with BE / dysplasia (median) Baseline Prague (CM) median Baseline multifocal dysplasia (n, %) Baseline HGD (n, %) RFA procedures (median) 12 mo fragments (n) 12 mo fragments with IM (n, % total)
CR-IM
IR-IM
29 (83%) 24 (83%) 64 (59-69) 26.5 (25-31) 3.4 / 0.6 1.5 / 4.0 21 (72%) 9 (31%) 4 806 0 (0%)
6 (17%) 5 (83%) 70.5 (64-74) 28.9 (27-32) ) 6.0 / 2.2 4.5 / 6.5 6 (100%) 3 (50%) 4 266 25 (9.3%)
results obtained indicates that the volunteers that had ED showed some degree of GERE, higher age band and lower level of schooling.
M1328 Prevalence of Complicated Gastroesophageal Reflux Disease and Barrett’s Esophagus Among Racial Groups in a Multi-Center Consortium Amy Wang, Nora Mattek, David A. Lieberman, Glenn M. Eisen Background and Aims: Current belief is that Caucasians are more likely to develop complicated gastroesophageal reflux disease (GERD) and/or Barrett’s esophagus (BE), although evidence to support this ethnic predilection is lacking. The aim of this study was to estimate the frequency of complicated GERD and suspected BE among various racial groups using the Clinical Outcomes Research Initiative (CORI) database. Methods: The CORI database was searched between January 2000 and December 2005 to identify unique adult patients who underwent upper endoscopy for any indication, as well as those undergoing endoscopy for indications of interest: dyspepsia, reflux symptoms, and BE screening. Procedures for BE surveillance were excluded. Racial groups were identified as white non-Hispanic (WNH), black non-Hispanic (BNH), Hispanic, and Asian/Pacific Islander (API). Chisquare analysis was used to compare categorical variables and multiple logistic regression was used to measure adjusted relative risks. Results: A total of 280,075 procedures were examined (82% WNH, 8% BNH, 8% Hispanic, 2% API). Reflux was the most frequent indication of interest for all groups except API. Hispanic subjects were most likely to have esophagitis (Hispanic 23.2% vs. WNH 19.6% vs. BNH 17.4% vs. API 11.2%, p-value!0.0001). WNH subjects were most likely to have suspected BE (WNH 5.0% vs. Hispanic 2.9% vs. API 1.8% vs. BNH 1.5%, p-value!0.0001) and esophageal stricture (WNH 10.7% vs. BNH 6.2% vs. Hispanic 3.1% vs. API 1.8%, pvalue!0.0001). Examining endoscopies of specific indications of interest revealed similar trends for findings of esophagitis and esophageal stricture. When BE screening was an indication, API were most likely to have suspected BE (API 20.4% vs. WNH 18.5% vs. Hispanic 16.8% vs. BNH 9.2%, p-value Z 0.02). Among reflux/BE screening procedures adjusted for age and gender, Hispanics were most likely to have esophagitis (Hispanic OR Z 1.4, 95% CI: 1.33-1.48; WNH OR Z 1.0; BNH OR Z 0.77, 95% CI: 0.72-0.82; API OR Z 0.61, 95% CI: 0.53-0.71, p-value!0.0001), and WNH were most likely to have suspected BE (WNH OR Z 1.00; Hispanic OR Z 0.75, 95% CI: 0.67-0.83; API OR Z 0.48, 95% CI: 0.36-0.64; BNH OR Z 0.44, 95% CI: 0.37-0.51, p-value!0.0001). The number needed to endoscope to identify one case of suspected BE was lowest in WNH males older than 50 years of age who undergo upper endoscopy for reflux symptoms or BE screening. Conclusions: While suspected BE and esophageal stricture are more likely to be detected in WNH, esophagitis appears to occur more frequently in Hispanics. These predilections may help further define the role of upper endoscopy in the management of GERD among racial groups.
)p ! 0.05
M1327 Dental Erosion in Patients Carrying of Gastroesophageal Reflux Esophagitis Marilene B. Alves, Kiyoshi Hashiba, Eduardo A. Andre, Carlos A. Cappellanes, Daniel S. Vilas Boas, Esther G. Birman Background: The gastroesophageal reflux esophagitis (GERE) has a chronic distinguishing mark and epidemiological studies shows that 11% of the Brazilian population relate symptoms compatible with the reflux ones at the very least one time per week. The reduction of oral pH caused by the GERE can provoke the dissolution of the hydroxiapatite leading to the dental erosion (DE) signaling one of the consequences of the action of reflux. Aim: This study evaluated the degree of DE in the individuals in relation of the degree of GERE, age band and level of schooling. Methods: Had participated of our study, individuals with ages varying between 20 and 80 years old (mean Z 46,76 14,27) of both genders with endoscopic diagnosis of GERE (GERE group, n Z 120) and individuals with ages varying between 21 and 80 years old (mean Z 39,97 13,98) of both genders with normal endoscopic examination (non-GERE group, n Z 60), after signature of the informed consent. The volunteers of this research had been submitted to an high digestive endoscopy followed by a clinical oral examination. The GERE when present, was classified according to Savary-Miller scale and the DE when present, according to Eccles-Jenkins scale. The statistics analysis of the results was carried through by the Pearson’s Qui-square test. Results: The results have indicated that the GERE is a significant factor for the appearing of DE (p Z 0,02). All of volunteers DE carriers had some degree of esophagitis. The age band, as well, is a significant factor for the DE appearing (p Z 0,02): the higher the age band, the higher the degree of DE. The level of schooling is a highly significant factor for DE appearing (p Z 0,001): the lower the level of schooling, the higher the degree of DE. The gender isn’t a significant factor for DE appearing in comparison of the non-GERE group (p Z 0,18). Conclusions: The
AB182 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
M1329 Long Term Prognosis of ESD for the Superficial Esophageal Squamous Cell Carcinoma Tsuneo Oyama, Yoko Kitamura, Kinichi Hotta Introduction: Lymph node metastasis (LNM) of esophageal squamous cell carcinoma (SCC) has been reported to correlate closely with the invasion depth and lymph duct involvement. When the invasion depth was intraepitheliam (m1) or proper mucosa (m2), the LNM has been reported 0 %. When SCC contacted with muscularis mucosa (m3) or invaded to submucosal layer 200 micrometer or less (sm1), the LNM is 9 to 20%. Therefore, the Japanese Esophageal Association decided the standard and expanding indication of esophageal EMR as the lesions those invasion depth is m1 or m2 and m3 or sm1, respectively. En bloc resection is necessary for the precise pathological examination. Therefore, endoscopic submucosal dissection (ESD) was developed. However, the long term prognosis after esophageal ESD is obscure. Aims & Methods: The aim of this study is to analyze the outcome of esophageal SCC treated by ESD and clarify the long term prognosis after esophageal ESD. 177 SCC in 158 patients were treated by ESD from Jan. 2000 to Oct. 2006 at Saku Central Hospital. The median age and observation period was 68 (44-86) and 32 months (4-90). The patients were divided into three groups due to the invasion depth; m1-2, m3-sm1 and sm2-3. M1 or m2 patients were followed up by Endoscopy and CT scan once a year. M3 or deep were recommended to be treated by esophagectomy with lymph node dissection or chemo radio therapy (CRT). If the patients refused the additional treatment, they were followed up by endoscopy and CT scan, twice a year. 176 of 177 patients were followed up in this study. Result of ESD1. Complete resection : 94%. 2. Median tumor and resected size was 24 mm (3 - 65) and 38 mm (12-73).3. Complications: Perforation 0%, Delayed perforation 0.6%, Mediastinal emphysema 4.5% (8/177) and Stricture 7.3% (13/177) . 4. Local recurrence was 0%. Prognosis of ESD1. M1 or m2 group, n Z 111. The median age and observation period was 68 (44-82) and 32 months (4-90). 9 patients died of other diseases. 2. M3 or sm1 group, n Z 39The median age and observation period was 67 (50-82) and 32
www.giejournal.org