Endoscopic dilation of anastomotic strictures after laparoscopic bariatric surgery

*4370 TREATMENT OF B L E E D I N G P E P T I C ULCERS WITH COMBINATION OF EPINEPHRINE INJECTION AND ENDOSCOPIC HEMOCLIP APPLICATION Tju-Siang Chua, Kwong-Ming Fock, Tay-Meng Ng, Jen-Lock Khor, EngKiong Tee, Changi Gen Hosp, Singapore Singapore Introduction: Bleeding from peptic ulcers is a major cause of mortality and morbidity. Endoscopic hemoclip application has been reported to be a safe and effective method of achieving hemostasis in bleeding peptic ulcers. However, clinical trials on its efficacy are scarce. Alms: Our study aims to assess the efficacy of combination therapy with epinephrine injection and hemoclip application in the treatment of bleeding peptic ulcers and to compare the clinical outcome between patients treated with such a combination therapy and those treated with epinephrine injection alone. Patients and Methods: A total of 293 patients (211 males, 82 females) underwent endoscopic therapy for bleeding peptic ulcers. 202 patients (152 males, 50 females) received epinephrine injection therapy (Group 1). Of these, 82 (40.6%) had actively bleeding ulcers, 102 (50.5%) had visible vessel, and 18 (8.9%) had an adherent clot. 91 patients (59 males, 32 females) received combination therapy (Group 2). Of these, 46 (50.5%) had actively bleeding ulcers, 42 (46.2%) had visible vessel, and 3 (3.3%) had an adherent clot. The choice of endoscopic therapy was made by the endoscopist. Hemostatic rates, rebleeding rates, need for emergency surgery and 30-day mortality were the outcome measures studied. Results: Group 1 patients were significantly younger (mean age 61±17 years, range 21 to 89 years) compared to Group 2 patients (mean age 66±16 years, range 24 to 90 years). Group 1 patients had less concomitant illnesses with 61.4% having at least one other chronic illness compared to Group 2 patients where 72.5% had at least one other chronic illness. Initial hemostasis was achieved in 199 (98.5%) patients in Group 1 and 91 (100%) patients in Group 2. The rebleeding rate was significantly lower in Group 1 compared to Group 2 (4% vs 11%). Emergency surgery was required in 3 (1.5%) patients in Group 1 and 1 (1.0%) in Group 2. The 30-day mortality was 11 (5.5%) and 6 (6.6%) in Groups 1 and 2 respectively. Conclusion: Although the rebleeding rate in our study was higher in the group treated with combination therapy, this group was more elderly and had more cemorbid medical conditions. Despite this, combination therapy managed to achieve a 100% initial hemostasis rate and have an acceptable rebleeding rate of 11%. Combination therapy with epinephrine injection and endoscopic hemoclip application is a safe and effective method for treatment of bleeding peptic ulcers in elderly patients with comorbid medical conditions. "4371 E N D O S C O P I C DILATION OF ANASTOMOTIC STRICTURES AFTER LAPAROSCOPIC BARIATRIC SURGERY Kenneth Miller, Mount Sinai Hospital/Division of Gastroenterology, New York, NY; Theresa Quinn, John De Csepel, mount sinai hospital/division of laparescepic Surg, .New York, NY; James George, mount sinai hospital/division of gastroenterology, New York, NY; Michel Gagner, Mount Sinai Hospital/Division of Laparoscopic Surg, New York, NY; David Jaffe, Anthony Weiss, Mount Sinai Hospital/Division of Gastroenterology, New York, NY BACKGROUND: Morbid obesity is a serious and common health problem for which medical treatment often fails. An increasing number of surgical procedures are performed for the treatment of obesity. Anastomotic stricture is the most common operative complication that occurs after bariatric surgery. Without an effective endoscopic therapy for these strictures, operative revision would be necessary. METHODS: We reviewed all cases of symptomatic anastomotic strictures occurring at~ver bariatric surgery that required endoscopic dilation over a 2 year period at our medical center. If the stricture did net allow passage of a standard endoscope, a through the scope (TTS) balloon dilator was used. If the standard upper endoscope could pass the anastomosis, this alone was used to dilate the stricture. When the efferent segment of the Roux limb could he entered without the need to torque the endoscope, a Maloney dilator was passed after dilation with the endoscope. RESULTS: Forty-one patients required 67 dilations. Ninety eight percent (40/41) of patients had a Roux-en-Y gastric bypass and the remaining patient underwent a biliopancreatic diversion with duodenal switch. Almost all of the patients (40/41) became asymptematic after dilation. One patient had a perforation during the third attempt at dilation and required an operative revision of the anastomosis. Another patient had a perforation after dilation that was treated nonoperatively, giving an overall perforation rate of 2/41 (5%). Fifty-six percent (23/41) required a single dilation, 27% (11141) required 2 dilations, and 15% (6/41) required 3 or more dilations. Eighty-seven percent (58/67) of the dilations were performed using the Microvasive CRE TM TTS balloon. Neither the time interval from surgery to the first dilation, the size of the balloon used, or method of dilation, predicted a response to the first dilation. Ten percent (4141) of the patients had intraoperative anastomotic leaks identified on methylene

AB214

GASTROINTESTINAL ENDOSCOPY

blue testing. All 4 of these patients required more than a single dilation. CONCLUSIONS: Endoscopic dilation of anastomotic strictures after laparoscopic bariatric surgery is both safe and effective. The majority of patients become asymptomatic after a single endoscopic dilation. The presence of an intraoperative leak may predict those patients who require more than a single endoscopic dilation. *4372 EARLY GASTRIC CANCER IN THE UNITED STATES: FAILURE OF ENDOSCOPY TO INCREASE DETECTION Fang Qian, Jeffery S. Jhang, Peter Green, Heidrun Rotterdam, Govind Bhagat, New York Presbyterian Hosp, New York, NY Background: Increasing numbers of upper gastrointestinal (UGI) endoscopies have been thought to be responsible for increasing the yield of early gastric carcinoma (EGC) in the United States (US) and Japan. More than 50% of resections for gastric cancer are for EGC in Japan. We decided to study ongoing trends in detecting EGC in a medical center in the US. Methods: We reviewed the demographic data, medical records and histopathology of patients (pts) with gastric cancer diagnosed by endoscopic biopsies (n=336) at our institute over a ten year period (1990-2000) and compared it with similar retrospective data (n=549) accrued between 1965-1980. Standard statistical analyses were performed. Results: 193 of 338 pts underwent gastric resection, 110 M (mean age 69±14 yrs, range 2989), 83 F (mean age 70±15 yrs, range 29-97). 311193 (16%) pts (20M, llF, mean age 70±14 yrs) had EC-C compared to 17% (40M, 29F, mean age 66.2±12 yrs) in the period 1975-1984 (9% prior to 1975). 19% of the pts had proximal carcinomas while 81% had distal carcinomas compared to 32% proximal and 68% distal during 1965-1980. Intestinal metaplasia was associated with EGC in 74% pts of our group compared with 89% in the earlier study. Tumor differentiation and type were similar to the previous study. EGC was detected more often in males (p<0.05) but did not correlate with age, tumor type, or tumor differentiation. In patients <40 yrs only 1118 (6%) had EGC. EGC was detected more often in Caucasians (55%) as compared to African Americans (19%), Hispanic (19%), and Asians (6%). Conclusions: Despite an increase in the number of UGI endoscopies performed at our medical center, the rate of detection of EGC has remained unchanged. Criteria for endoscopy and surveillance strategies need to be reevaluated in order to be effective in detecting early disease and decreasing mortality from gastric cancer.

*4373 A P R O S P E C T I V E , RANDOMIZED, CONTROLLED TRIAL ASSESSING THE BENEFIT OF UPPER ENDOSCOPY PERFORMED IN HEMODYNAMICALLY STABLE PATIENTS WITH ACUTE U P P E R GASTROINTESTINAL BLEEDING WITHIN SIX HOURS OF PRESENTATION TO THE EMERGENCY DEPARTMENT. Jeffrey A. Smith, Joel T Bruggen, Wake Forest Univ Sch of Medicine, Winston-Salem, NC Background: In upper gastrointestinal (GI) bleeding, therapeutic endoscopy has been shown to significantly reduce further bleeding, blood transfusions, hospital stay and cost, emergency surgery, and mortality. There are few studies which have investigated how the timing of endoscopy alters the outcome in patients with an acute upper GI bleed. Methods: Patients were included if they had clinical evidence of upper GI bleeding and were hemodynamically stable (SBP>90, HR