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Development of Barrett's Esophagus After Erosive Esophagitis
Abstracts
S1315 Surveillance of Barrett’s Esophagus: Impact of a Multifaceted Intervention On the Implementation of Guidelines Nassira Amamra, Sandrine Touzet, Cyrille Colin, Thierry Ponchon Objective: Guidelines concerning the endoscopic surveillance of patients with Barrett’s esophagus (BE) are not well followed by hepatogastroenterologists (HGE), as demonstrated by several national enquiries. This low compliance is a major concern for the national scientific societies. The main objective of this study was to evaluate if an agressive multifaceted intervention could improve the compliance of HGE to these guidelines. Methods: The multifaceted intervention concerning guidelines on the surveillance of Barrett’s esophagus took place between 2003 and 2004, during 18 months. It associated reminders (stickers to be apposed on the screen of the videoendoscope, information booklets and posters), repeated oral specific communications during post-graduate courses, repeated mails (reviews, actualities on BE) and working tools such as a planimetry and a small reminder on surveillance of BE to be given to the patient. We conducted a postal survey using an anonymous declarative questionaire before (June 2002) and after (June 2005) the multifaceted intervention. We included all of the 245 HGEs of the same region (5.5 millions inhabitants) working in private or public structures. Eight criteria defined the compliance with the guidelines. Results:In 2002 and 2005, the response rates to the questionaire were respectively 81.3% and 72.2% after two sendings. The results are presented in the following table: PrePost-interventionSystematic biopsies 72.5% 88.1% p ! 0.01. Systematic surveillance 61% 68.4% NS4-quadrant biopsies / 2 cm if circular BE 58% 79% p ! 0.01/2 cm on each tongue of BE 34% 67% p ! 0.012-3 year interval surveillance if no dysplasia 78% 89% p ! 0,016-12 month interval F-U if low grade dysplasia 78% 81% NS2nd histological lecture if high grade dysplasia 29% 54% p ! 0.01 repeated biopsies / PPI if high grade dysplasia 42% 42% NSAfter adjustment on the characteristics of the physicians, the differences observed remained statistically significant. The 2 main factors associated with a lower compliance to the guidelines identified by the hepatogastroenterologists were the poor patient tolerance to the examination and the cost of the surveillance. Conclusion: 1- Our multifaceted intervention allowed a significant improvement of the compliance to the tissue sampling protocol, which is usually considered as time-consuming 2- When applied, the surveillance seems to comply with guidelines and the intervals between examinations are followed 3- However, the problem is still for one third of HGE to launch the systematic surveillance and we propose a new intervention targeted on this aspect.
S1316 Development of Barrett’s Esophagus After Erosive Esophagitis Nir Modiano, Shahin Shahnia, Lauren B. Gerson Background: Barrett’s esophagus (BE) is present in 8-20% of GERD patients. Canine models have suggested the development of BE after induction of esophageal injury. A prior study (Hanna, Am J Gastro 2006) demonstrated that 12% of patients with erosive esophagitis (EE) had BE on subsequent endoscopy (EGD) performed within 11 weeks. The purpose of this study was to determine the development of BE after initial EE using a large database. Methods: We identified patients with diagnosis of reflux esophagitis, acute esophagitis, or esophageal stricture by primary or secondary ICD-9 codes of 530.0, 530.3, 530.11, or 530.12 between 1996-2006. Patients were eligible for study entry if at least 2 EGDs were performed. Exclusion criteria included no EGD or 1 EGD, BE on the initial EGD, or stricture associated with gastrointestinal or head and neck cancer. Results: We screened 1116 patients; 102 (9%) patients with EE were included. We excluded 852 patients with no or 1 EGD, 120 patients with prior or initial BE, and 42 patients prior malignancy. The mean SEM age of the included cohort was 58 1.4 years (range 24-83), 15% were female, 80% Caucasian, and 60% veterans. The mean number of EGDs performed was 3.2 0.2 (range 2-12) over a mean number of 25 2.6 (range 0.5-108) months. 91% of patients had EE present on first EGD (31% stage 2, 11% stage 3, 37% stage 4), 52% on the second exam, and 29% on the third EGD, and 28% on subsequent EGDs. The most common indication for the first EGD was dysphagia in 31%, GERD in 31%, and upper GI bleeding in 21%. 56% of patients had biopsies on initial EGD showing ulceration in 30%, inflammation in 32%, infection in 4% and normal tissue in 35%. In the 89% of patients with available medication profiles, 34% of patients were taking PPI therapy at time of index EGD, while 71% used PPI during the second EGD. Nine percent of patients had EE or a normal index EGD followed by BE on a subsequent examination over a mean of 13.3 5.7 months (range 1-53.5 months). The mean length of BE was 4 1.8 cm (range 1-18 cm, 5 patients had SSBE with a length of 1 cm). 56% of the patients who developed BE had initial normal esophageal biopsies or biopsies with inflammation while the remainder did not have biopsies performed. Using the formula p Z 1-e(rate)time), the calculated yearly probability for development of BE was 9% per year. Conclusions: Approximately 9% of patients with erosive esophagitis will develop BE or have BE detected on a subsequent endoscopic examination. Esophageal biopsies should be performed in the presence of esophageal erosions, and repeat examinations should occur after PPI therapy to assess for the presence of BE.
AB142 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
S1317 Low Incidence of Adenocarcinoma and High Grade Dysplasia in Patients with Barrett’s Esophagus: A Prospective Cohort Study Jan Martinek, Julius Spicak, Marek Benes, Juraj Marcek, Michal Vasicek, Eva Tomsova Background and Aims: Barrett’s oesophagus (BE) is a premalignat condition and periodic endoscopic surveillance programme with biopsies is recommended. The real risk of development of high-grade dysplasia (HGD) or adenocarcinoma (AC) is a matter of discussion. Older studies probably overestimated the risk due to several shortcomings (definition of BE, definition of dysplasia, treatment of patients). The aim of our study was to investigate the incidence of low-grade dysplasia (LGD), HGD and AC in a cohort of patients with BE. Methods: A prospective, cohort study in 151 patients with BE. All patients had histologically confirmed intestinal metaplasia and macroscopic evidence of short (less then 3 cm) or long (equal or more than 3 cm) segment of BE. All patients underwent a standard protocol including regular endoscopic examinations with biopsies. Chromoendoscopy (or narrow band imaging) was used in all patients. The patients were treated with a high dose of a proton pump inhibitor ( H2-receptor antagonist) or underwent an antireflux surgery. One hundred thirty five patients were included into the analysis. Results: One hundred thirty five patients underwent 476 endoscopies during 527 patient-years of follow-up (mean 4.3). There were 45 subjects (33.3%) with long segment and 90 (66.7%) subjects with short segment BE. LGD was detected in 23 subjects (17%; in 14 patients with short and in 9 patients with long segment BE). In 9 of those patients, LGD was detected at index endoscopy (prevalent LGD) and in only 1 subject it has been detected during subsequent endoscopies. In remaining 14 patients, LGD was detected 1-7 years after an index endoscopy. At present, only 4 of them have LGD. Both HGD and AC were detected in one patient with long segment BE two years after an index endoscopy. The patient was treated with endoscopic mucosal resection and argon-plasma coagulation. Our study shows an incidence of HGD/AC in Barrett’s oesophagus of 1 in 527 patient-years. Interestingly, the endoscopic regression of BE was seen in 28 (20.8%) of subjects while the mild progression only in 3 (2.2%) subjects. Conclusion: The incidence of HGD/AC in patients with BE being adequately treated is low - the annual risk of developing HGD/AC is 0.19% (0.68% in long segment BE). We hypothesised that an effective antisecretory treatment may change the natural course of patients with BE by decreasing the risk of development of HGD/AC.
S1318 Endoscopic Closure of Chronic Cervical Esophageal Fistulas: Initial Experience Douglas A. Howell, Burr J. Loew, Harsha Vittal, Michael K. Sanders, Kirk P. Bernadino, Roy A. Cobean, Lou Russo Recent reports have emphasized an evolving role for endoscopic treatment of refractory benign esophageal conditions (GIE 2005:62;278-286). However, few report endoscopic treatment of extremely high surgical esophageal fistulas. Patients and Methods: Four patients (M:3/ F:1, age 44-60) presented with chronic cervical esophageal cutaneous fistulas 29 to 300 days post-operatively following anastomotic breakdown of attempted Zenker’s diverticulectomy (n Z 2), and cervical esophagogastrostomy after esophagectomy (n Z 2). The fistulas were measured from the incisors at endoscopy at 15, 16, 18, and 22 cm and were associated with severe stricture in 2. Two patients had had no oral intake for O6 months. Patient treatment included: placement of removable plastic stents (Polyflex, Boston Scientific (n Z 2) and silicone 10 mm salivary duct stents (n Z 1)), and endoscopic cricopharyngeal myotomy with stapled suture lines (n Z 1). Dilation (n Z 2), fibrin-glue fistula sealant under the stents (n Z 2), and a guiding NG tube before the endoscopic cricopharyngeal myotomy (n Z 1) were also used. Results: Fistulas closed immediately in all but reopened in one upon stent migration. This was eventually sealed with repeat stent placement x2 and required fibrin-glue (Tisseal, Baxter) at the final procedure. The stents produced only brief patient discomfort and were otherwise well tolerated. Swallowing resumed in the stented patients within 24 hours with full liquids to soft diet. All four of the Polyflex stents migrated into the stomach (3 in 1 case and 1 in another), but were easily removed perorally via EGD. The final silicone salivary stent migrated distally to lie below the strictured anastomosis and was removed endoscopically through an existing G-tube site. No bleeding or aspiration occurred. All stents have now been removed (3 to a maximum 6 weeks after definitive closure) and patients are undergoing well-tolerated dilations when needed. Conclusions: Endoscopic closure of high cervical fistulas can be effectively performed using new techniques and technologies. These treatments were well tolerated, appeared to be safe, and produced excellent results in four extremely difficult post-operative chronic esophageal fistula patients. Removable esophageal stents were key to rapid closure but distal migration was universal. The initial use of fibrin-glue might accelerate sealing and prevent fistula reopening when this occurs.
www.giejournal.org
S1315 Surveillance of Barrett’s Esophagus: Impact of a Multifaceted Intervention On the Implementation of Guidelines Nassira Amamra, Sandrine Touzet, Cyrille Colin, Thierry Ponchon Objective: Guidelines concerning the endoscopic surveillance of patients with Barrett’s esophagus (BE) are not well followed by hepatogastroenterologists (HGE), as demonstrated by several national enquiries. This low compliance is a major concern for the national scientific societies. The main objective of this study was to evaluate if an agressive multifaceted intervention could improve the compliance of HGE to these guidelines. Methods: The multifaceted intervention concerning guidelines on the surveillance of Barrett’s esophagus took place between 2003 and 2004, during 18 months. It associated reminders (stickers to be apposed on the screen of the videoendoscope, information booklets and posters), repeated oral specific communications during post-graduate courses, repeated mails (reviews, actualities on BE) and working tools such as a planimetry and a small reminder on surveillance of BE to be given to the patient. We conducted a postal survey using an anonymous declarative questionaire before (June 2002) and after (June 2005) the multifaceted intervention. We included all of the 245 HGEs of the same region (5.5 millions inhabitants) working in private or public structures. Eight criteria defined the compliance with the guidelines. Results:In 2002 and 2005, the response rates to the questionaire were respectively 81.3% and 72.2% after two sendings. The results are presented in the following table: PrePost-interventionSystematic biopsies 72.5% 88.1% p ! 0.01. Systematic surveillance 61% 68.4% NS4-quadrant biopsies / 2 cm if circular BE 58% 79% p ! 0.01/2 cm on each tongue of BE 34% 67% p ! 0.012-3 year interval surveillance if no dysplasia 78% 89% p ! 0,016-12 month interval F-U if low grade dysplasia 78% 81% NS2nd histological lecture if high grade dysplasia 29% 54% p ! 0.01 repeated biopsies / PPI if high grade dysplasia 42% 42% NSAfter adjustment on the characteristics of the physicians, the differences observed remained statistically significant. The 2 main factors associated with a lower compliance to the guidelines identified by the hepatogastroenterologists were the poor patient tolerance to the examination and the cost of the surveillance. Conclusion: 1- Our multifaceted intervention allowed a significant improvement of the compliance to the tissue sampling protocol, which is usually considered as time-consuming 2- When applied, the surveillance seems to comply with guidelines and the intervals between examinations are followed 3- However, the problem is still for one third of HGE to launch the systematic surveillance and we propose a new intervention targeted on this aspect.
S1316 Development of Barrett’s Esophagus After Erosive Esophagitis Nir Modiano, Shahin Shahnia, Lauren B. Gerson Background: Barrett’s esophagus (BE) is present in 8-20% of GERD patients. Canine models have suggested the development of BE after induction of esophageal injury. A prior study (Hanna, Am J Gastro 2006) demonstrated that 12% of patients with erosive esophagitis (EE) had BE on subsequent endoscopy (EGD) performed within 11 weeks. The purpose of this study was to determine the development of BE after initial EE using a large database. Methods: We identified patients with diagnosis of reflux esophagitis, acute esophagitis, or esophageal stricture by primary or secondary ICD-9 codes of 530.0, 530.3, 530.11, or 530.12 between 1996-2006. Patients were eligible for study entry if at least 2 EGDs were performed. Exclusion criteria included no EGD or 1 EGD, BE on the initial EGD, or stricture associated with gastrointestinal or head and neck cancer. Results: We screened 1116 patients; 102 (9%) patients with EE were included. We excluded 852 patients with no or 1 EGD, 120 patients with prior or initial BE, and 42 patients prior malignancy. The mean SEM age of the included cohort was 58 1.4 years (range 24-83), 15% were female, 80% Caucasian, and 60% veterans. The mean number of EGDs performed was 3.2 0.2 (range 2-12) over a mean number of 25 2.6 (range 0.5-108) months. 91% of patients had EE present on first EGD (31% stage 2, 11% stage 3, 37% stage 4), 52% on the second exam, and 29% on the third EGD, and 28% on subsequent EGDs. The most common indication for the first EGD was dysphagia in 31%, GERD in 31%, and upper GI bleeding in 21%. 56% of patients had biopsies on initial EGD showing ulceration in 30%, inflammation in 32%, infection in 4% and normal tissue in 35%. In the 89% of patients with available medication profiles, 34% of patients were taking PPI therapy at time of index EGD, while 71% used PPI during the second EGD. Nine percent of patients had EE or a normal index EGD followed by BE on a subsequent examination over a mean of 13.3 5.7 months (range 1-53.5 months). The mean length of BE was 4 1.8 cm (range 1-18 cm, 5 patients had SSBE with a length of 1 cm). 56% of the patients who developed BE had initial normal esophageal biopsies or biopsies with inflammation while the remainder did not have biopsies performed. Using the formula p Z 1-e(rate)time), the calculated yearly probability for development of BE was 9% per year. Conclusions: Approximately 9% of patients with erosive esophagitis will develop BE or have BE detected on a subsequent endoscopic examination. Esophageal biopsies should be performed in the presence of esophageal erosions, and repeat examinations should occur after PPI therapy to assess for the presence of BE.
AB142 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 5 : 2007
S1317 Low Incidence of Adenocarcinoma and High Grade Dysplasia in Patients with Barrett’s Esophagus: A Prospective Cohort Study Jan Martinek, Julius Spicak, Marek Benes, Juraj Marcek, Michal Vasicek, Eva Tomsova Background and Aims: Barrett’s oesophagus (BE) is a premalignat condition and periodic endoscopic surveillance programme with biopsies is recommended. The real risk of development of high-grade dysplasia (HGD) or adenocarcinoma (AC) is a matter of discussion. Older studies probably overestimated the risk due to several shortcomings (definition of BE, definition of dysplasia, treatment of patients). The aim of our study was to investigate the incidence of low-grade dysplasia (LGD), HGD and AC in a cohort of patients with BE. Methods: A prospective, cohort study in 151 patients with BE. All patients had histologically confirmed intestinal metaplasia and macroscopic evidence of short (less then 3 cm) or long (equal or more than 3 cm) segment of BE. All patients underwent a standard protocol including regular endoscopic examinations with biopsies. Chromoendoscopy (or narrow band imaging) was used in all patients. The patients were treated with a high dose of a proton pump inhibitor ( H2-receptor antagonist) or underwent an antireflux surgery. One hundred thirty five patients were included into the analysis. Results: One hundred thirty five patients underwent 476 endoscopies during 527 patient-years of follow-up (mean 4.3). There were 45 subjects (33.3%) with long segment and 90 (66.7%) subjects with short segment BE. LGD was detected in 23 subjects (17%; in 14 patients with short and in 9 patients with long segment BE). In 9 of those patients, LGD was detected at index endoscopy (prevalent LGD) and in only 1 subject it has been detected during subsequent endoscopies. In remaining 14 patients, LGD was detected 1-7 years after an index endoscopy. At present, only 4 of them have LGD. Both HGD and AC were detected in one patient with long segment BE two years after an index endoscopy. The patient was treated with endoscopic mucosal resection and argon-plasma coagulation. Our study shows an incidence of HGD/AC in Barrett’s oesophagus of 1 in 527 patient-years. Interestingly, the endoscopic regression of BE was seen in 28 (20.8%) of subjects while the mild progression only in 3 (2.2%) subjects. Conclusion: The incidence of HGD/AC in patients with BE being adequately treated is low - the annual risk of developing HGD/AC is 0.19% (0.68% in long segment BE). We hypothesised that an effective antisecretory treatment may change the natural course of patients with BE by decreasing the risk of development of HGD/AC.
S1318 Endoscopic Closure of Chronic Cervical Esophageal Fistulas: Initial Experience Douglas A. Howell, Burr J. Loew, Harsha Vittal, Michael K. Sanders, Kirk P. Bernadino, Roy A. Cobean, Lou Russo Recent reports have emphasized an evolving role for endoscopic treatment of refractory benign esophageal conditions (GIE 2005:62;278-286). However, few report endoscopic treatment of extremely high surgical esophageal fistulas. Patients and Methods: Four patients (M:3/ F:1, age 44-60) presented with chronic cervical esophageal cutaneous fistulas 29 to 300 days post-operatively following anastomotic breakdown of attempted Zenker’s diverticulectomy (n Z 2), and cervical esophagogastrostomy after esophagectomy (n Z 2). The fistulas were measured from the incisors at endoscopy at 15, 16, 18, and 22 cm and were associated with severe stricture in 2. Two patients had had no oral intake for O6 months. Patient treatment included: placement of removable plastic stents (Polyflex, Boston Scientific (n Z 2) and silicone 10 mm salivary duct stents (n Z 1)), and endoscopic cricopharyngeal myotomy with stapled suture lines (n Z 1). Dilation (n Z 2), fibrin-glue fistula sealant under the stents (n Z 2), and a guiding NG tube before the endoscopic cricopharyngeal myotomy (n Z 1) were also used. Results: Fistulas closed immediately in all but reopened in one upon stent migration. This was eventually sealed with repeat stent placement x2 and required fibrin-glue (Tisseal, Baxter) at the final procedure. The stents produced only brief patient discomfort and were otherwise well tolerated. Swallowing resumed in the stented patients within 24 hours with full liquids to soft diet. All four of the Polyflex stents migrated into the stomach (3 in 1 case and 1 in another), but were easily removed perorally via EGD. The final silicone salivary stent migrated distally to lie below the strictured anastomosis and was removed endoscopically through an existing G-tube site. No bleeding or aspiration occurred. All stents have now been removed (3 to a maximum 6 weeks after definitive closure) and patients are undergoing well-tolerated dilations when needed. Conclusions: Endoscopic closure of high cervical fistulas can be effectively performed using new techniques and technologies. These treatments were well tolerated, appeared to be safe, and produced excellent results in four extremely difficult post-operative chronic esophageal fistula patients. Removable esophageal stents were key to rapid closure but distal migration was universal. The initial use of fibrin-glue might accelerate sealing and prevent fistula reopening when this occurs.
www.giejournal.org