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Endoscopic Cricopharyngeal Myotomy for Zenker Diverticulum: Evaluation of Technical and Clinical Results
Abstracts
S1495 Experience with 1,345 Esophageal Cancer Patients Seen At a Single Mission Hospital in Western Kenya Russell E. White, Zachariah Kasepoi, Gavin C. Harewood, Thomas Ng, William Cioffi, Mark Topazian Objective: To evaluate demographic, endoscopic, and pathologic findings, management and outcome in a large series of esophageal cancer (EC) patients. Methods: Records for all patients presenting with EC to a single institution in western Kenya between January, 1998 and September, 2005 were reviewed. Data for patients receiving self expanding metallic stents (SEMS) were collected prospectively, as was all survival data, while the remainder was collected retrospectively. Results: 1,345 patients were seen. Squamous cell carcinoma accounted for 86% of cases. The male:female ratio was 1.7:1, and average age was 57 years (range 14-99 years), with 16% of patients %40 years of age. Symptomatic obstruction requiring endoscopic dilatation was found in 976 cases (95% of cases with complete records). Perforation occurred in 28 dilatations (2.9%); 25 were treated with SEMS (one death and 24 recovered) and 3 were treated surgically (all died). SEMS were placed in 452 patients and 52 patients were treated surgically, while a large number of patients declined further treatment. Complications occurred in 10% of patients receiving SEMS, with stent obstruction due to tumor accounting for 70% of complications. Median survival following SEMS placement was 9 months. The mean dysphagia score improved from 3.3 to 2.2 (p ! .01) before stenting and at the time of death respectively. In the surgical group, complete R0 resection was accomplished in 41 cases with an operative mortality of 14%, and complication rate of 50%. Incomplete resection (less than R0) was carried out in 6 cases with 4 deaths (67% mortality). The majority of surgical cases were stage III and IV (71%). Overall median survival following surgery was 24 months; 27 months for stage I and II, and 12 months for stage III and IV (p Z .02). Conclusions: Esophageal squamous cell cancer is common in western Kenya, and a large number of patients present at a young age. Placement of SEMS is a reasonable palliative treatment in patients who are not surgical candidates, and is also the treatment of choice for perforation during dilation. Complete R0 resection can be carried out with acceptable morbidity and mortality in advanced stage disease in a rural mission hospital setting. If R0 resection cannot be achieved, then SEMS placement should be considered rather than incomplete resection. Future work should be directed at identification of early stage disease and selection of patients who would benefit most from surgical resection.
S1496 Flexible Endoscopy As a Diagnostic Tool for Esophageal Injuries: Large Experience from a Trauma Center Vitor Arantes, Claudio Campolina, Silvia Valerio, Roberta Nogueira Sa, Colodomiro Toledo, V. Coelho Luiz Gonzaga Background: The successful management and clinical outcome of patients suffering esophageal trauma depends on a prompt diagnosis. The detection of esophageal injuries by clinical suspicion, esophagography or CT is far from perfect. There is scarce retrospective data on the role of flexible endoscopy (FE) in esophageal trauma. Aims: To assess the yield, safety and clinical utility of FE on the diagnosis of suspected esophageal injuries in trauma victims. Methods: Over a seven year period, we conducted a retrospective (1998 to 2003) and prospective (2003 to 2005) study of patients (pts) submitted to an urgent FE, requested by the attending traumatologist, due to suspected esophageal trauma. Exclusion criteria: death or transferal before 72 hours of clinical follow-up, and esophageal strictures precluding complete examination. Esophageal injury was defined as laceration (full-thickness wound with perforation) and contusion (mucosal abrasion with localized hyperemia and hematin spots or clots, without perforation, in a site close to the bullet path, attributed to a thermal energy from the gunshot). The endoscopic diagnosis was compared to surgical findings or clinical follow-up. Results: 163 pts were enrolled, 153 males (93.9%) and 10 females (6.1%), mean age 27 years (7-78 years). Mechanism of injury: 131 gunshot wounds (80.4%), 27 stab wounds (16.6%) and 5 blunt trauma (3.1%). Time for FE from admission: 12 hours 70.5%, 12 to 24 hours - 11.6%, after 24 hours - 17.9%. FE findings: no traumatic lesion in 139 pts (85.3%), esophageal injuries in 23 pts (14.1%), inconclusive in one case (esophageal stricture, 0.6%). Lacerations were detected in 14 pts, all confirmed surgically. Contusions were observed in 10 pts. The first six cases were operated, and esophageal wall damage from the bullet path without perforation was noted. The past four cases with esophageal contusion without signs of perforation were managed conservatively. True-positive procedures occurred for 23 pts, true-negative results for 119 pts, false-negative exam for one case, and no false-positive examination. Overall FE showed 95.8% sensitivity, 100% specificity, 100% positive predictive value, 99.2% negative predictive value, and 99.3% accuracy. One complication was registered (aspiration pneumonia). Conclusion: FE is a highly accurate and safe diagnostic tool in the assessment of esophageal injuries. Endoscopists should be alert on two main lesions: laceration or perforation and contusion. Laceration usually requires surgical repair. Esophageal contusion, in selected cases, may be managed in a more conservative manner.
AB124 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
S1497 Endoscopic Cricopharyngeal Myotomy for Zenker Diverticulum: Evaluation of Technical and Clinical Results Federico Iacopini, Michele Marchese, Andrea Tringali, Pietro Familiari, Cristiano Spada, Vincenzo Perri, Alberto Larghi, Domenico Galasso, Guido Costamagna Background: Standard treatments of Zenker diverticulum are endoscopic stapled diverticulotomy and crycopharingeal myotomy associated or not with either transcervical diverticulectomy or diverticulopexis. Endoscopic flexible diverticulotomy is a mini-invasive alternative. Aim: To evaluate the immediate results and the clinical efficacy at 1 months follow-up of flexible endoscopic myotomy. Methods: A total of 35 patients (74% males; mean age 67 G 12 years) with Zenker diverticulum (median length 4 cm; range 2-8) were treated in a 5 years period. The endoscopic device used to expose the diverticular septum was the oblique-end plastic hood (MH589, Olympus; Japan) in 26 patients and the flexible double duckbill diverticuloscope (Wilson-Cook, USA) in 9 patients. Myotomy was performed by needle-knife with endocut current (200 ICC, ERBE). Severity of dysphagia for solids and liquids, regurgitation, chronic cough and nocturnal symptoms were graded according to frequency (0, none; 1, weekly; 2 daily) before the procedure and after 1 month. Results: Zenker diverticula had a median depth of 4 cm: 3 (9%) were !3 cm; 23 (66%) were 3-4 cm, and 9 (26%) were O4 cm. Dysphagia and regurgitation were the most common symptoms and were both reported by 94% of patients. Cough, either during meals and/or postprandial was present in 80% patients and nocturnal symptoms in 77%. Myotomy was performed in a single endoscopic session in 94% of patients and in two sessions in 6%. Minor bleeding during the cut was observed in 3 (9%) cases but was easily controlled by electrocoagulation, epinephrine injection or endoclips. Complications occurred in 4 (10%) cases: in two patients a perforation was observed during the procedure and was closed with endoclips, and in two cases subcutaneous emphysema and pneumo-mediastinum were noted 24 hrs after endoscopy. All patients were treated conservatively and discharged after one week. Hospital stay ranged from 2 to 8 days (median 4 days). Dysphagia for solids, regurgitation and chronic cough improved significantly after treatment. All symptoms disappeared in 8 (23%) patients. Four (11%) patients required retreatment and 4 (11%) eventually underwent surgical diverticulectomy. Conclusions: Flexible endoscopic cricopharyngeal myotomy is feasible both for large and small Zenker diverticula and achieves a significant clinical improvement. Extension of the cut of the septum in case of partial clinical response may be successful in a proportion of patients.
S1498 Treatment of Barrett’s Esophagus and High-Grade Dysplasia Using the HALO-360 Ablation System: A Multi-Center Experience Robert Ganz, Gene Overholt, Masoud Panjehpour, Steve Demeester, Shiro Urayama, Steve Freeman, Thomas Savides, Victor Eysselein, Virender Sharma, Malcolm Branch, David Fleischer Background: Current management of patients with Barrett’s esophagus (BE) and high-grade dysplasia (HGD) includes esophagectomy and photodynamic therapy. Both modalities entail considerable morbidity and, in some cases, mortality. We established a U.S. registry to assess the safety and efficacy of an alternative endoscopic modality for patients with BECHGD, i.e. circumferential radiofrequency (RF) ablation using the HALO-360 Ablation System. Methods: The registry is comprised of 9 U.S. centers, each with a comprehensive Barrett’s program. Work-up for BECHGD typically included one or more of the following; confirmation of HGD by 2 pathologists, CT, EUS, and EMR for nodules. The ˆ RRX Medical, Sunnyvale, CA) is comprised of a sizing HALO-360 Ablation System (BA balloon, a balloon-based RF electrode, and an energy generator. The sizing balloon precisely measures the inner diameter of the targeted esophagus using a novel pressure/volume system. Thereafter, circumferential RF ablation is performed using an ultra-short pulse of RF energy (300 W) and a fixed amount of energy density (12 J/cm2), typically resulting in complete ablation to the level of the muscularis mucosae with preservation of the submucosa. Post-ablation, all patients receive high dose PPIs along with continued endoscopic surveillance, typically every 3 months, with 4 quadrant biopsies every 1-2 cm. Complete response (CR) for HGD is defined as no histologic evidence of HGD in any biopsy per follow-up interval. If HGD is present at follow-up, patients are eligible for a second ablation. Results: From Sept 2004 to Dec 2005, 40 pts were treated with the HALO-360 Ablation System (37 male, mean age 67 yrs). Median baseline BE length was 5 cm (IQR 3-9). There were no serious adverse events and no strictures. Follow-up is available for 22 pts (range 3-15 mos) after a mean of 1.1 ablation sessions. Mean endoscopic regression of BE surface area was 96% (IQR 94-100). CR for HGD occurred in 73% of pts (50% normal, 18% non-dysplastic IM, 5% LGD). Five pts have residual HGD in a single area of BE, and will have repeat ablation. In 2 of these 5 pts, ablation was incomplete due to a pre-existing BE stricture. One pt had a small intramucosal adenocarcinoma 1-mo post-ablation, deemed pre-existing/occult, and received esophagectomy. Although not a primary endpoint, a CR for BE occurred in 50% of pts. Conclusions: Ablation of BECHGD using the HALO-360 Ablation System is a viable alternative to esophagectomy or PDT. Ablations were performed safely with no strictures, and can be repeated for residual HGD or BE. The registry permits the continued tracking of safety data and efficacy related to this technique.
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S1495 Experience with 1,345 Esophageal Cancer Patients Seen At a Single Mission Hospital in Western Kenya Russell E. White, Zachariah Kasepoi, Gavin C. Harewood, Thomas Ng, William Cioffi, Mark Topazian Objective: To evaluate demographic, endoscopic, and pathologic findings, management and outcome in a large series of esophageal cancer (EC) patients. Methods: Records for all patients presenting with EC to a single institution in western Kenya between January, 1998 and September, 2005 were reviewed. Data for patients receiving self expanding metallic stents (SEMS) were collected prospectively, as was all survival data, while the remainder was collected retrospectively. Results: 1,345 patients were seen. Squamous cell carcinoma accounted for 86% of cases. The male:female ratio was 1.7:1, and average age was 57 years (range 14-99 years), with 16% of patients %40 years of age. Symptomatic obstruction requiring endoscopic dilatation was found in 976 cases (95% of cases with complete records). Perforation occurred in 28 dilatations (2.9%); 25 were treated with SEMS (one death and 24 recovered) and 3 were treated surgically (all died). SEMS were placed in 452 patients and 52 patients were treated surgically, while a large number of patients declined further treatment. Complications occurred in 10% of patients receiving SEMS, with stent obstruction due to tumor accounting for 70% of complications. Median survival following SEMS placement was 9 months. The mean dysphagia score improved from 3.3 to 2.2 (p ! .01) before stenting and at the time of death respectively. In the surgical group, complete R0 resection was accomplished in 41 cases with an operative mortality of 14%, and complication rate of 50%. Incomplete resection (less than R0) was carried out in 6 cases with 4 deaths (67% mortality). The majority of surgical cases were stage III and IV (71%). Overall median survival following surgery was 24 months; 27 months for stage I and II, and 12 months for stage III and IV (p Z .02). Conclusions: Esophageal squamous cell cancer is common in western Kenya, and a large number of patients present at a young age. Placement of SEMS is a reasonable palliative treatment in patients who are not surgical candidates, and is also the treatment of choice for perforation during dilation. Complete R0 resection can be carried out with acceptable morbidity and mortality in advanced stage disease in a rural mission hospital setting. If R0 resection cannot be achieved, then SEMS placement should be considered rather than incomplete resection. Future work should be directed at identification of early stage disease and selection of patients who would benefit most from surgical resection.
S1496 Flexible Endoscopy As a Diagnostic Tool for Esophageal Injuries: Large Experience from a Trauma Center Vitor Arantes, Claudio Campolina, Silvia Valerio, Roberta Nogueira Sa, Colodomiro Toledo, V. Coelho Luiz Gonzaga Background: The successful management and clinical outcome of patients suffering esophageal trauma depends on a prompt diagnosis. The detection of esophageal injuries by clinical suspicion, esophagography or CT is far from perfect. There is scarce retrospective data on the role of flexible endoscopy (FE) in esophageal trauma. Aims: To assess the yield, safety and clinical utility of FE on the diagnosis of suspected esophageal injuries in trauma victims. Methods: Over a seven year period, we conducted a retrospective (1998 to 2003) and prospective (2003 to 2005) study of patients (pts) submitted to an urgent FE, requested by the attending traumatologist, due to suspected esophageal trauma. Exclusion criteria: death or transferal before 72 hours of clinical follow-up, and esophageal strictures precluding complete examination. Esophageal injury was defined as laceration (full-thickness wound with perforation) and contusion (mucosal abrasion with localized hyperemia and hematin spots or clots, without perforation, in a site close to the bullet path, attributed to a thermal energy from the gunshot). The endoscopic diagnosis was compared to surgical findings or clinical follow-up. Results: 163 pts were enrolled, 153 males (93.9%) and 10 females (6.1%), mean age 27 years (7-78 years). Mechanism of injury: 131 gunshot wounds (80.4%), 27 stab wounds (16.6%) and 5 blunt trauma (3.1%). Time for FE from admission: 12 hours 70.5%, 12 to 24 hours - 11.6%, after 24 hours - 17.9%. FE findings: no traumatic lesion in 139 pts (85.3%), esophageal injuries in 23 pts (14.1%), inconclusive in one case (esophageal stricture, 0.6%). Lacerations were detected in 14 pts, all confirmed surgically. Contusions were observed in 10 pts. The first six cases were operated, and esophageal wall damage from the bullet path without perforation was noted. The past four cases with esophageal contusion without signs of perforation were managed conservatively. True-positive procedures occurred for 23 pts, true-negative results for 119 pts, false-negative exam for one case, and no false-positive examination. Overall FE showed 95.8% sensitivity, 100% specificity, 100% positive predictive value, 99.2% negative predictive value, and 99.3% accuracy. One complication was registered (aspiration pneumonia). Conclusion: FE is a highly accurate and safe diagnostic tool in the assessment of esophageal injuries. Endoscopists should be alert on two main lesions: laceration or perforation and contusion. Laceration usually requires surgical repair. Esophageal contusion, in selected cases, may be managed in a more conservative manner.
AB124 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
S1497 Endoscopic Cricopharyngeal Myotomy for Zenker Diverticulum: Evaluation of Technical and Clinical Results Federico Iacopini, Michele Marchese, Andrea Tringali, Pietro Familiari, Cristiano Spada, Vincenzo Perri, Alberto Larghi, Domenico Galasso, Guido Costamagna Background: Standard treatments of Zenker diverticulum are endoscopic stapled diverticulotomy and crycopharingeal myotomy associated or not with either transcervical diverticulectomy or diverticulopexis. Endoscopic flexible diverticulotomy is a mini-invasive alternative. Aim: To evaluate the immediate results and the clinical efficacy at 1 months follow-up of flexible endoscopic myotomy. Methods: A total of 35 patients (74% males; mean age 67 G 12 years) with Zenker diverticulum (median length 4 cm; range 2-8) were treated in a 5 years period. The endoscopic device used to expose the diverticular septum was the oblique-end plastic hood (MH589, Olympus; Japan) in 26 patients and the flexible double duckbill diverticuloscope (Wilson-Cook, USA) in 9 patients. Myotomy was performed by needle-knife with endocut current (200 ICC, ERBE). Severity of dysphagia for solids and liquids, regurgitation, chronic cough and nocturnal symptoms were graded according to frequency (0, none; 1, weekly; 2 daily) before the procedure and after 1 month. Results: Zenker diverticula had a median depth of 4 cm: 3 (9%) were !3 cm; 23 (66%) were 3-4 cm, and 9 (26%) were O4 cm. Dysphagia and regurgitation were the most common symptoms and were both reported by 94% of patients. Cough, either during meals and/or postprandial was present in 80% patients and nocturnal symptoms in 77%. Myotomy was performed in a single endoscopic session in 94% of patients and in two sessions in 6%. Minor bleeding during the cut was observed in 3 (9%) cases but was easily controlled by electrocoagulation, epinephrine injection or endoclips. Complications occurred in 4 (10%) cases: in two patients a perforation was observed during the procedure and was closed with endoclips, and in two cases subcutaneous emphysema and pneumo-mediastinum were noted 24 hrs after endoscopy. All patients were treated conservatively and discharged after one week. Hospital stay ranged from 2 to 8 days (median 4 days). Dysphagia for solids, regurgitation and chronic cough improved significantly after treatment. All symptoms disappeared in 8 (23%) patients. Four (11%) patients required retreatment and 4 (11%) eventually underwent surgical diverticulectomy. Conclusions: Flexible endoscopic cricopharyngeal myotomy is feasible both for large and small Zenker diverticula and achieves a significant clinical improvement. Extension of the cut of the septum in case of partial clinical response may be successful in a proportion of patients.
S1498 Treatment of Barrett’s Esophagus and High-Grade Dysplasia Using the HALO-360 Ablation System: A Multi-Center Experience Robert Ganz, Gene Overholt, Masoud Panjehpour, Steve Demeester, Shiro Urayama, Steve Freeman, Thomas Savides, Victor Eysselein, Virender Sharma, Malcolm Branch, David Fleischer Background: Current management of patients with Barrett’s esophagus (BE) and high-grade dysplasia (HGD) includes esophagectomy and photodynamic therapy. Both modalities entail considerable morbidity and, in some cases, mortality. We established a U.S. registry to assess the safety and efficacy of an alternative endoscopic modality for patients with BECHGD, i.e. circumferential radiofrequency (RF) ablation using the HALO-360 Ablation System. Methods: The registry is comprised of 9 U.S. centers, each with a comprehensive Barrett’s program. Work-up for BECHGD typically included one or more of the following; confirmation of HGD by 2 pathologists, CT, EUS, and EMR for nodules. The ˆ RRX Medical, Sunnyvale, CA) is comprised of a sizing HALO-360 Ablation System (BA balloon, a balloon-based RF electrode, and an energy generator. The sizing balloon precisely measures the inner diameter of the targeted esophagus using a novel pressure/volume system. Thereafter, circumferential RF ablation is performed using an ultra-short pulse of RF energy (300 W) and a fixed amount of energy density (12 J/cm2), typically resulting in complete ablation to the level of the muscularis mucosae with preservation of the submucosa. Post-ablation, all patients receive high dose PPIs along with continued endoscopic surveillance, typically every 3 months, with 4 quadrant biopsies every 1-2 cm. Complete response (CR) for HGD is defined as no histologic evidence of HGD in any biopsy per follow-up interval. If HGD is present at follow-up, patients are eligible for a second ablation. Results: From Sept 2004 to Dec 2005, 40 pts were treated with the HALO-360 Ablation System (37 male, mean age 67 yrs). Median baseline BE length was 5 cm (IQR 3-9). There were no serious adverse events and no strictures. Follow-up is available for 22 pts (range 3-15 mos) after a mean of 1.1 ablation sessions. Mean endoscopic regression of BE surface area was 96% (IQR 94-100). CR for HGD occurred in 73% of pts (50% normal, 18% non-dysplastic IM, 5% LGD). Five pts have residual HGD in a single area of BE, and will have repeat ablation. In 2 of these 5 pts, ablation was incomplete due to a pre-existing BE stricture. One pt had a small intramucosal adenocarcinoma 1-mo post-ablation, deemed pre-existing/occult, and received esophagectomy. Although not a primary endpoint, a CR for BE occurred in 50% of pts. Conclusions: Ablation of BECHGD using the HALO-360 Ablation System is a viable alternative to esophagectomy or PDT. Ablations were performed safely with no strictures, and can be repeated for residual HGD or BE. The registry permits the continued tracking of safety data and efficacy related to this technique.
www.giejournal.org