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Endoscopic Mucosal Resection (EMR) for Barrett's High Grade Dysplasia (HGD) and Early Esophageal Adenocarcinoma (EAC): An Essential Staging Procedure with Long-Term Therapeutic Benefit
Abstracts
Background: Zenker’s diverticulum arises from the hypopharinx. Main symptoms comprise oropharyngeal dysphagia and food regurgitation, but choking, chronic cough, and aspiration can also occur. Surgical approach through a laterocervical access and endoscopic stapling technique are the standard treatments. Although flexible endoscopic diverticulotomy is less invasive, there are no prospective data of the long-term clinical results. Aim: To prospectively assess clinical efficacy of flexible endoscopic diverticulotomy of Zenker’s diverticulum by the diverticuloscopeassisted technique. Method: From March 2005 to November 2007, 21 consecutive patients with Zenker’s diverticulum were enrolled. diverticulotomy was conducted by the soft diverticuloscope-assisted technique. After the placement of the soft diverticuloscope, the septum was cut with a needle knife, and the distal margin was sealed with an endoclip. Dysphagia, pharyngo oral regurgitation, daytime respiratory symptoms (cough, asthma, hoarseness), and nightly symptoms were prospectively recorded before the procedure, 1 month postoperatively (early), and in November 2008 (late follow-up). Symptoms were scored according to frequency: 0 Z absent; 1 Z occasional (once or twice per week); 2 Z frequent (daily); and 3 Z constant (at each meal) (Eckardt score). Clinical remission was defined as the disappearance of all symptoms or as the occasional persistence of no more than 2 symptoms. Results: Compared to pre-treatment, severity of all symptoms was significantly lower both early after treatment (P!0.001) and at the end of follow-up (median 2.1 yrs, range 1-4) (PZ0.001). However, severity of dysphagia increased within the long-term follow-up (PZ0.02) recurring severely in 4 patients, whereas regurgitation, day-time respiratory and night-time symptoms were persistently absent in almost all patients (PZn.s.). Clinical remission was achieved in 16/ 21(76%) in the early, and 62% (13/21) in late follow-up (median 2 yrs, range 1-3). The multivariate analysis showed that neither sex, age (%70/O70 yrs), or size of the diverticulum (%3/O3 cm) were significant independent prognostic factor for clinical efficacy. Conclusions: Flexible endoscopic diverticuloscope-assisted Zenker’s diverticulotomy seems to completely resolve the symptoms in almost 2/3 of patients. Severity of Zenker’s-related symptoms before and after flexible endoscopic treatment (mean ± SD).
Pretreatment After 1 month After 2 years PZ
Food Daytime respiratory Dysphagia regurgitation symptoms
Night-tyme symptoms
2.7 0.7
2.5 0.5
1.2 1
1.0 1.0
0.6 0.8
0.8 1.0
0.2 0.5
0.1 0.2
1.1 1.2
1.0 1.1
0.4 0.9
0.2 0.7
0.003
0.003
0.001
0.0005
W1348 Retrospective Analysis of Endoscopic Balloon Dilatation (EBD) for Benign Fibrotic Strictures After Curative Non-Surgical Treatment for Esophageal Cancer (EC) Yusuke Yoda, Tomonori Yano, Shinya Tsuruta, Keiko Minashi, Hiroaki Ikematsu, Kazuhiro Kaneko, Atsushi Ohtsu Background: Dysphagia caused by a benign fibrotic stricture is the major problem for patients (pts) with esophageal cancer (EC) treated with curative treatment. Endoscopic balloon dilatation (EBD) has been reported safe and effective intervention for anastomatic strictures after esophagectomy. However, little is known about the safety and efficacy of EBD for benign fibrotic strictures after nonsurgical treatments such as chemoradiotherapy (CRT) or endoscopic mucosal resection (EMR). Aim: To evaluate retrospectively the safety and efficacy of EBD for benign fibrotic strictures after CRT or EMR for pts with EC, and to compare with EBD for stricture after esophagectomy. Patients and Methods: The selection criteria of this study were as follow; 1) pts who achieve cure with curative treatment for EC, 2) pts who complained of dysphagia and for whom an endoscope could not pass their stricture. The balloon size was chosen based on the degree of their stricture. We usually choose CRE (Boston Scientific) balloon,15-18mm in diameter and 8cm long. If the stricture was severe (!5mm in diameter), we choose thinner balloons. The balloon was positioned at the middle of the stricture, and carefully inflated under fluoroscopic guidance until the stricture disappeared or the pts‘ discomfort appeared. After EBD, if a perforation was suspected, we confirmed using CT. EBD was repeated once a week to once a month depending on the grade of dysphagia, and it was continued until the dysphagia had resolved. We classified pts into three groups based on their treatment for EC, a CRT group (Gp-C); an EMR group (Gp-E) and a surgery group (Gp-S). We compared the complications rate and efficacy of EBD between groups. Written informed consent was obtained from all the pts before EBD. Results: From Jan 2005 to Dec 2007, we performed 3673 EBDs in our institution. We selected 1105 EBDs for 121 pts with EC according to our criteria (male/female 102/19, median age 65 years). There were 390 EBDs for 31 pts in GpC, 329 EBDs for 31 pts in Gp-E and 386 EBDs for 59 pts in Gp-S. The median times and durations of EBD in all pts were 8 times and 5 M (6 and 11 M in Gp-C. 9 and 4 M in Gp-E. 5 and 3 M in Gp-S). Perforation occurred in 3 of 1105 sessions (0.3%; 0 in
AB348 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
Gp-C, 1 in Gp-E, 2 in Gp-S). There was no case of bleeding requiring intervention or blood transfusion in all sessions. Of 121 pts, 87 (80.3%) resolved their dysphagia and relieved from repeated EBDs (83.3% in Gp-C, 86.7% in Gp-E and 78.4% in GpS). Conclusion: EBD for benign fibrotic strictures after non-surgical treatment such as CRT or EMR for EC is equivalently safe and effective compared EBD for strictures after esophagectomy.
W1349 Endoscopic Mucosal Resection (EMR) for Barrett’s High Grade Dysplasia (HGD) and Early Esophageal Adenocarcinoma (EAC): An Essential Staging Procedure with Long-Term Therapeutic Benefit Alan Moss, Michael J. Bourke, Luke F. Hourigan, Saurabh Gupta, Michael P. Swan, Andrew D. Hopper, Vu Kwan, Adam A. Bailey, Stephen J. Williams Background and Aim: Patients with Barrett’s HGD or EAC confirmed with repeat endoscopy and biopsy continue to undergo esophagectomy (with significant morbidity and mortality) on the basis of biopsy staging alone. EMR is a potential alternative that may provide both definitive local tumor staging and treatment. Furthermore, Complete Barrett’s Excision (CBE) by EMR holds promise as a cure for short segment Barrett’s esophagus. However, only limited long-term outcome data is available. This 2 center prospective study evaluates the efficacy, safety, effect on staging, and long-term outcome of EMR for Barrett’s HGD or EAC and for CBE in suitable patients. Methods: All patients (nZ66) undergoing EMR for repeat biopsy confirmed Barrett’s HGD or EAC from 2001-8 were prospectively included. CBE by 2-3 stage radical mucosectomy was attempted for Barrett’s segments %3cm in patients aged !75 with minimal comorbidity. Surveillance endoscopy post-EMR utilized high resolution endoscopy, acetic acid spray and narrow band imaging, with targeted biopsies of EMR sites plus 4 quadrant biopsies every 1cm. In CBE suitable cases, EMR was performed every 6 weeks until CBE achieved. Results: Pre-EMR histology was HGD 59 (89%) and EAC 7 (11%). Barrett’s segment length range was 1-11 cm (mean 3.5). Technique was multiband mucosectomy in 2/3 and Inoue cap in 1/3. Technical success was 100%, with mean specimen size 14 x 9 x 3 mm. PostEMR histology was HGD 36 (55%), low grade dysplasia (LGD) 10 (15%), mucosal adenocarcinoma 9 (14%), submucosal adenocarcinoma 7 (11%), and no dysplasia 3 (5%). EMR resulted in change in stage in 45% compared with biopsy (downstaging 16 (26%), up-staging 12 (19%)). 88% required 1-2 EMR sessions only. CBE was successful in 22/29 (76%) of attempted cases overall, but in 100% of the last 15. Complications included one case of aspiration requiring 2 night hospital admission with full recovery and 3 cases of functionally significant stricture successfully treated with endoscopic dilatation. During follow-up (mean 32 months; median 31; range 3-85) there were no Barrett’s related deaths and 5 patients underwent esophagectomy for EMR demonstrated submucosal invasion. Esophagectomy specimens revealed T0 N0 M0 in 3 and T1 N0 M0 in 2. Conclusions: EMR for Barrett’s HGD or EAC is safe and effective and a definitive treatment for most. An EMR strategy alters staging in almost half the cases compared to biopsy, and dramatically reduces the need for esophagectomy. CBE is consistently achievable for short segment Barrett’s once the learning curve is overcome. Therefore, EMR is both a critical staging tool, and a viable therapeutic alternative to surgery.
W1350 N-2-Butyl-Cyanoacrilate: An Effective Option for the Treatment of Gastric Varices Augusto Villaverde, Fernando Baldoni, Alberto Bernedo, Horacio Martinez, Francisco Tufare, Nestor A. Chopita Aim: to evaluate the efficacy of hystoacryl in primary hemostasis, rebleeding and eradication of gastric varices. Patients and Methods: since January 1999 to January 2007, 65 patients with bleeding for gastric varices were treated in our unit with n-2butyl-cyanoacrylate. A mixture of 0.5 ml of hystoacryl and 0.5 ml of lypiodol was used with a maximum of two ml. per session. Sclerotherapy needles of 21 g, Olympus endoscopes (145 series) and sedation with midazolam were used in all patients. Data was analyzed by chi-square test. Results: we included 65 patients, 42 males and 23 females with a mean age of 53.8 years, range 18-77. The patients were classified as Child A 28, Child B 24 and Child C 6; seven patients were not classified. According to Sarin classification 17 patients presented GOV 1 varices, 32 GOV 2, 8 GOV 1 y 2 and 8 IGV 1. Fifty six patients (86.1%) had active bleeding or recent bleeding stigmata at the moment of the endoscopy. Primary hemostasis was achieved in 89.28% (50 patients) in agreement with Baveno IV. Eleven patients with rebleeding were retreated with hystoacryl. Definitive hemostasis was successful in 8 of them, 2 were sent to surgical treatment and 1 to endovascular therapy. After the definitive hemostasis the patients were discharged on propanolol . After one year of follow up, 7 patients re-bled (12.5%) and they were all successfully treated endoscopically . The gastric varices were eradicated in 21 of 63 patients (33.87%) with recurrence in 6 patients (28.57%) without any complication. Conclusion: in our series, primary hemostasis was achieved in 89.28% and definitive hemostasis in 95.38% of the patients studied. Complete eradication of gastric varices was obtained in 33.87%. During the follow up 28.57% of these patients had a recurrence. We
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Background: Zenker’s diverticulum arises from the hypopharinx. Main symptoms comprise oropharyngeal dysphagia and food regurgitation, but choking, chronic cough, and aspiration can also occur. Surgical approach through a laterocervical access and endoscopic stapling technique are the standard treatments. Although flexible endoscopic diverticulotomy is less invasive, there are no prospective data of the long-term clinical results. Aim: To prospectively assess clinical efficacy of flexible endoscopic diverticulotomy of Zenker’s diverticulum by the diverticuloscopeassisted technique. Method: From March 2005 to November 2007, 21 consecutive patients with Zenker’s diverticulum were enrolled. diverticulotomy was conducted by the soft diverticuloscope-assisted technique. After the placement of the soft diverticuloscope, the septum was cut with a needle knife, and the distal margin was sealed with an endoclip. Dysphagia, pharyngo oral regurgitation, daytime respiratory symptoms (cough, asthma, hoarseness), and nightly symptoms were prospectively recorded before the procedure, 1 month postoperatively (early), and in November 2008 (late follow-up). Symptoms were scored according to frequency: 0 Z absent; 1 Z occasional (once or twice per week); 2 Z frequent (daily); and 3 Z constant (at each meal) (Eckardt score). Clinical remission was defined as the disappearance of all symptoms or as the occasional persistence of no more than 2 symptoms. Results: Compared to pre-treatment, severity of all symptoms was significantly lower both early after treatment (P!0.001) and at the end of follow-up (median 2.1 yrs, range 1-4) (PZ0.001). However, severity of dysphagia increased within the long-term follow-up (PZ0.02) recurring severely in 4 patients, whereas regurgitation, day-time respiratory and night-time symptoms were persistently absent in almost all patients (PZn.s.). Clinical remission was achieved in 16/ 21(76%) in the early, and 62% (13/21) in late follow-up (median 2 yrs, range 1-3). The multivariate analysis showed that neither sex, age (%70/O70 yrs), or size of the diverticulum (%3/O3 cm) were significant independent prognostic factor for clinical efficacy. Conclusions: Flexible endoscopic diverticuloscope-assisted Zenker’s diverticulotomy seems to completely resolve the symptoms in almost 2/3 of patients. Severity of Zenker’s-related symptoms before and after flexible endoscopic treatment (mean ± SD).
Pretreatment After 1 month After 2 years PZ
Food Daytime respiratory Dysphagia regurgitation symptoms
Night-tyme symptoms
2.7 0.7
2.5 0.5
1.2 1
1.0 1.0
0.6 0.8
0.8 1.0
0.2 0.5
0.1 0.2
1.1 1.2
1.0 1.1
0.4 0.9
0.2 0.7
0.003
0.003
0.001
0.0005
W1348 Retrospective Analysis of Endoscopic Balloon Dilatation (EBD) for Benign Fibrotic Strictures After Curative Non-Surgical Treatment for Esophageal Cancer (EC) Yusuke Yoda, Tomonori Yano, Shinya Tsuruta, Keiko Minashi, Hiroaki Ikematsu, Kazuhiro Kaneko, Atsushi Ohtsu Background: Dysphagia caused by a benign fibrotic stricture is the major problem for patients (pts) with esophageal cancer (EC) treated with curative treatment. Endoscopic balloon dilatation (EBD) has been reported safe and effective intervention for anastomatic strictures after esophagectomy. However, little is known about the safety and efficacy of EBD for benign fibrotic strictures after nonsurgical treatments such as chemoradiotherapy (CRT) or endoscopic mucosal resection (EMR). Aim: To evaluate retrospectively the safety and efficacy of EBD for benign fibrotic strictures after CRT or EMR for pts with EC, and to compare with EBD for stricture after esophagectomy. Patients and Methods: The selection criteria of this study were as follow; 1) pts who achieve cure with curative treatment for EC, 2) pts who complained of dysphagia and for whom an endoscope could not pass their stricture. The balloon size was chosen based on the degree of their stricture. We usually choose CRE (Boston Scientific) balloon,15-18mm in diameter and 8cm long. If the stricture was severe (!5mm in diameter), we choose thinner balloons. The balloon was positioned at the middle of the stricture, and carefully inflated under fluoroscopic guidance until the stricture disappeared or the pts‘ discomfort appeared. After EBD, if a perforation was suspected, we confirmed using CT. EBD was repeated once a week to once a month depending on the grade of dysphagia, and it was continued until the dysphagia had resolved. We classified pts into three groups based on their treatment for EC, a CRT group (Gp-C); an EMR group (Gp-E) and a surgery group (Gp-S). We compared the complications rate and efficacy of EBD between groups. Written informed consent was obtained from all the pts before EBD. Results: From Jan 2005 to Dec 2007, we performed 3673 EBDs in our institution. We selected 1105 EBDs for 121 pts with EC according to our criteria (male/female 102/19, median age 65 years). There were 390 EBDs for 31 pts in GpC, 329 EBDs for 31 pts in Gp-E and 386 EBDs for 59 pts in Gp-S. The median times and durations of EBD in all pts were 8 times and 5 M (6 and 11 M in Gp-C. 9 and 4 M in Gp-E. 5 and 3 M in Gp-S). Perforation occurred in 3 of 1105 sessions (0.3%; 0 in
AB348 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
Gp-C, 1 in Gp-E, 2 in Gp-S). There was no case of bleeding requiring intervention or blood transfusion in all sessions. Of 121 pts, 87 (80.3%) resolved their dysphagia and relieved from repeated EBDs (83.3% in Gp-C, 86.7% in Gp-E and 78.4% in GpS). Conclusion: EBD for benign fibrotic strictures after non-surgical treatment such as CRT or EMR for EC is equivalently safe and effective compared EBD for strictures after esophagectomy.
W1349 Endoscopic Mucosal Resection (EMR) for Barrett’s High Grade Dysplasia (HGD) and Early Esophageal Adenocarcinoma (EAC): An Essential Staging Procedure with Long-Term Therapeutic Benefit Alan Moss, Michael J. Bourke, Luke F. Hourigan, Saurabh Gupta, Michael P. Swan, Andrew D. Hopper, Vu Kwan, Adam A. Bailey, Stephen J. Williams Background and Aim: Patients with Barrett’s HGD or EAC confirmed with repeat endoscopy and biopsy continue to undergo esophagectomy (with significant morbidity and mortality) on the basis of biopsy staging alone. EMR is a potential alternative that may provide both definitive local tumor staging and treatment. Furthermore, Complete Barrett’s Excision (CBE) by EMR holds promise as a cure for short segment Barrett’s esophagus. However, only limited long-term outcome data is available. This 2 center prospective study evaluates the efficacy, safety, effect on staging, and long-term outcome of EMR for Barrett’s HGD or EAC and for CBE in suitable patients. Methods: All patients (nZ66) undergoing EMR for repeat biopsy confirmed Barrett’s HGD or EAC from 2001-8 were prospectively included. CBE by 2-3 stage radical mucosectomy was attempted for Barrett’s segments %3cm in patients aged !75 with minimal comorbidity. Surveillance endoscopy post-EMR utilized high resolution endoscopy, acetic acid spray and narrow band imaging, with targeted biopsies of EMR sites plus 4 quadrant biopsies every 1cm. In CBE suitable cases, EMR was performed every 6 weeks until CBE achieved. Results: Pre-EMR histology was HGD 59 (89%) and EAC 7 (11%). Barrett’s segment length range was 1-11 cm (mean 3.5). Technique was multiband mucosectomy in 2/3 and Inoue cap in 1/3. Technical success was 100%, with mean specimen size 14 x 9 x 3 mm. PostEMR histology was HGD 36 (55%), low grade dysplasia (LGD) 10 (15%), mucosal adenocarcinoma 9 (14%), submucosal adenocarcinoma 7 (11%), and no dysplasia 3 (5%). EMR resulted in change in stage in 45% compared with biopsy (downstaging 16 (26%), up-staging 12 (19%)). 88% required 1-2 EMR sessions only. CBE was successful in 22/29 (76%) of attempted cases overall, but in 100% of the last 15. Complications included one case of aspiration requiring 2 night hospital admission with full recovery and 3 cases of functionally significant stricture successfully treated with endoscopic dilatation. During follow-up (mean 32 months; median 31; range 3-85) there were no Barrett’s related deaths and 5 patients underwent esophagectomy for EMR demonstrated submucosal invasion. Esophagectomy specimens revealed T0 N0 M0 in 3 and T1 N0 M0 in 2. Conclusions: EMR for Barrett’s HGD or EAC is safe and effective and a definitive treatment for most. An EMR strategy alters staging in almost half the cases compared to biopsy, and dramatically reduces the need for esophagectomy. CBE is consistently achievable for short segment Barrett’s once the learning curve is overcome. Therefore, EMR is both a critical staging tool, and a viable therapeutic alternative to surgery.
W1350 N-2-Butyl-Cyanoacrilate: An Effective Option for the Treatment of Gastric Varices Augusto Villaverde, Fernando Baldoni, Alberto Bernedo, Horacio Martinez, Francisco Tufare, Nestor A. Chopita Aim: to evaluate the efficacy of hystoacryl in primary hemostasis, rebleeding and eradication of gastric varices. Patients and Methods: since January 1999 to January 2007, 65 patients with bleeding for gastric varices were treated in our unit with n-2butyl-cyanoacrylate. A mixture of 0.5 ml of hystoacryl and 0.5 ml of lypiodol was used with a maximum of two ml. per session. Sclerotherapy needles of 21 g, Olympus endoscopes (145 series) and sedation with midazolam were used in all patients. Data was analyzed by chi-square test. Results: we included 65 patients, 42 males and 23 females with a mean age of 53.8 years, range 18-77. The patients were classified as Child A 28, Child B 24 and Child C 6; seven patients were not classified. According to Sarin classification 17 patients presented GOV 1 varices, 32 GOV 2, 8 GOV 1 y 2 and 8 IGV 1. Fifty six patients (86.1%) had active bleeding or recent bleeding stigmata at the moment of the endoscopy. Primary hemostasis was achieved in 89.28% (50 patients) in agreement with Baveno IV. Eleven patients with rebleeding were retreated with hystoacryl. Definitive hemostasis was successful in 8 of them, 2 were sent to surgical treatment and 1 to endovascular therapy. After the definitive hemostasis the patients were discharged on propanolol . After one year of follow up, 7 patients re-bled (12.5%) and they were all successfully treated endoscopically . The gastric varices were eradicated in 21 of 63 patients (33.87%) with recurrence in 6 patients (28.57%) without any complication. Conclusion: in our series, primary hemostasis was achieved in 89.28% and definitive hemostasis in 95.38% of the patients studied. Complete eradication of gastric varices was obtained in 33.87%. During the follow up 28.57% of these patients had a recurrence. We
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