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Esophageal Endoscopic Mucosal Resection for Early Cancer and High Grade Dysplasia
Abstracts
S1533 Radiofrequency Correction of GERD (Stretta) Results in Significant, Long Term 4-Year Improvement in Symptoms, Quality of Life and Medication Use in the Medically Refractory GERD Patient Mark D. Noar, Sahar Lotfi A single center, intent to treat, trial of long-term efficacy and safety of the Stretta procedure for treatment of medically refractory GERD despite multi-dose PPI medical therapy was conducted. Methods: Beginning August 2000, 109 subjects with documented GERD and/or regurgitation and inadequate symptom control despite minimum bid PPI had an outpatient Stretta procedure via conscious sedation by one doctor (MN), and were followed for 4C years. Patients with normal anatomy, or failed Nissen, large (O3 cm) hiatal hernia, erosive esophagitis, and Barrett’s metaplasia were included. Exclusion criteria were: ASAOIII, collagen vascular disease, stricture, or achalasia. Baseline on/off meds and follow-up 6, 12, 24, 36, 48 months GERD-HRQL scores (0-50), heartburn (0-5), satisfaction (0-5) and medication-use were collected. All statistics performed with SAS or JUMP Statistical Analysis Software. Results: 109 subjects entered study. 13/109 failed to respond. 96 responders followed thru year 4. GERD-HRQL, heartburn, satisfaction, and medication use significantly improved at all follow-up intervals 6, 12, 24, 36, 48 months, (p ! 0.001) and were superior to those achieved on baseline drug therapy. At year 4, patients were divided into 4 medication use categories: 1) No meds, 2) PRN antacids/OTC PPI, 3) Daily PPI QD, 4) PPI BID. 75% of patients showed significant improvement into categories 1 or 2 (p ! 0.05). In all parameters, no significant difference between patient scores at baseline on or off meds was noted. A comparative analysis between patients with (33) and without (76) erosive esophagitis showed significant improvement in both groups with no difference between groups, with durability of results maintained to 4 years without statistical difference between the two groups (p O.7). Anatomic differences did not alter success or response to treatment. No acute adverse events or pathological histological changes occurred. Conclusions: 1) The Stretta procedure has a significant positive and sustained effect on medication use, HRQL, satisfaction and GERD symptoms, with durability of response demonstrated at 4 years, 2) The observed improvement was superior to that achieved with escalated baseline antisecretory therapy, and 3) There was no difference in response in patients with variant anatomy such as Nissen fundoplication, hiatal hernia, erosive esophagitis or Barrett’s esophagus.
group B were bedridden (p ! 0.01). NSAIDs users and alcohol consumers were estimated as 18.4%, 15.8% in group A and 25.6%, 19.2% in group B, respectively (p Z n.s). All of the hemorrhagic lesions in group A located in the lower third of the esophagus involving esophago-gastric junction, while in group B 62.8% of hemorrhagic lesions confined to the stomach, and 37.2% were associated with bulbitis. The prevalence of H. pylori infection was significantly lower in group A (29.2%) than in group B (73.6%) (p ! 0.0005). The histology of background gastric mucosa revealed that atrophy, active inflammation, and intestinal metaplasia were found in 36.8%, 31.6%, 5.3% in group A, and 72.9%, 66.1%, 17.7% in group B, respectively (p ! 0.05-0.005). Conclusion: Hemorrhagic esophagitis occurred exclusively in the elderlys who were inpatient or nursed supine for the underlying diseases. Majority with hemorrhagic esophagitis were negative for H. pylori, which suggested a scanty contribution of H. pylori infection to them, although H. pylori infection might have a certain relation to hemorrhagic gastroduodenitis.
Baseline Baseline P Off Meds On Meds 1 year 2 year 3 year 4 year Value Heartburn Score Total Heartburn Score Satisfaction Score Med Score O7 Z PPI BID NZ
3.6 27.8
2.6 20.5
0.9 6.8
0.7 4.6
1.08 6.7
1.18 7.1
P ! 0.001 P ! 0.001
1.4
2.2
3.97
4.4
3.8
3.8
P ! 0.001
8.43
3.62
3.53
4.3
4.1
P ! 0.005
109
108
102
96
S1534 The Prevalence of Helicobacter Pylori Infection in Patients with Acute Hemorrhagic Esophagitis Seiji Kimura, Masanori Tanaka Background and Aims: Acute hemorrhagic esophagitis is recognized as stressinduced mucosal injury and one of the uncommon source of upper gastrointestinal tract bleeding as well as hemorrhagic erosive gastroduodenitis. It has not been discussed whether H. pylori infection influences on these hemorrhagic mucosal lesions. The study aimed to evaluate the prevalence of H. pylori infection between patients with esophagitis and gastroduodenitis. Methods: The study included 116 patients who presented with upper gastrointestinal tract bleeding, and diagnosed as having hemorrhagic esophagitis (group A, n Z 38), or hemorrhagic gastroduodenitis (group B, n Z 78) by emergency esophagogastroduodenoscopy. Their clinicopathological findings, and the status of H. pylori infection were compared with each other group; H. pylori infection was determined by urease test, serology, and histology. Results: Mean age and sex ratio of patients in group A were 72.6Cÿ12.9 yr, range 34-89, and M:F Z 21:17, and those in group B were 63.1Cÿ15.8yr, range 23-84, and M:F Z 45:33, respectively. Elderlys more than 70 yr of age were more predominant in group A (71.1%) than group B (47.4%) (p ! 0.005), although no gender difference was noted. All patients in group A had background diseases such as cerebrovascular disease 31.6%, dementia 21.1%, diabetes 15.8%, ischemic heart disease 10.5%, though 32.1% of patients in group B had no background diseases. 89.5% in group A and 41.0% in group B received institutional care with nursing (p ! 0.0005), and 34.2% in group A and 11.5% in
AB134 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
S1535 Endoscopic Evaluation of Opportunistic Infections Inpos Renal Transplant Patients Thais G. Mourao, Paula A. Novais, Hanna B. Sa, Perla O. Schulz, Tais G. Andrade, Monica Soldan, Marcia H. Costa, Marilia S. Andrade, Celeste Elia, Cyrla Zaltman Introduction: All pos renal transplant patients need chronic use of immunosuppressive drugs, predisposing to opportunistic infections. Endoscopy is widely employed in the management of these patients with upper GI symptoms, being capable to confirm a suspected diagnosis of opportunist infection. The aim of this study is to evaluate the appropriateness of upper endoscopy in this special group of patients, trying to correlate the endoscopic and clinical features. Methods: A retrospective study enrolling 589 patients submitted to kidney transplant was done at HUCFF-UFRJ, Rio de Janeiro, Brazil, from 12/1994 to 12/2004. Demographic characteristics, prevalence of upper GI endoscopy done, symptoms (epigastric pain,nausea/vomit, upper GI bleeding, dysphagia and fever), endoscopic diagnosis (gastritis, esophagitis and duodenitis) and the histopathological detection of opportunistic infections (CMV, Herpes sp and Candida sp) were recorded. Statistical analysis was done with SPSS 11.0 software, with qui-quadrad test being used to evaluate the associations and 5% was considered acceptable as significance value. Results: From the 589 patients evaluated, 54,1% was female with mean age of 43 yrs (16-69 yrs). The upper GI endoscopy was required in 29,71% of the patients. The most common endoscopic indication was epigastric pain associated or not with others symptoms (49,6%), followed by: upper GI bleeding (18,9%), nausea/vomit (4,8%); dysphagia/odynophagia (4,8%), heartburn (3%), abdominal pain (1,9%), fever (0,4%) and others (8%). Endoscopy was normal in 15,4% of the cases. The endoscopic finding were gastritis (47%), infectious esophagitis (24,4%), reflux esophagitis (17,8%), duodenal peptic ulcer (7,4%) and infectious gastritis (3,3%). CMV was the most prevalent opportunistic detected agent (7,8%) followed by Candida sp (5,6%) and Herpes virus (3,7%). The c2 test was used to evaluate the correlation between epigastric pain and a noninfectious inflammation with a result of 76.116 (p Z 0.003). Considering the association between esophageal symptoms and the detection of infectious esophageal inflammation, the result was 76.341 (p Z 0.002). Conclusion: Among the renal transplant patients with upper GI symptoms, the epigastric pain was the most frequent indication for upper GI endoscopy, with a poor correlation with gastric opportunistic infection. On the contrary, a high correlation was seen between esophageal symptoms and opportunistic agents detected in the esophagus. We concluded that the presence of esophageal symptoms in this special group of patients must be used as an indicative parameter to evaluate opportunistic infections by upper GI endoscopy.
www.giejournal.org
S1533 Radiofrequency Correction of GERD (Stretta) Results in Significant, Long Term 4-Year Improvement in Symptoms, Quality of Life and Medication Use in the Medically Refractory GERD Patient Mark D. Noar, Sahar Lotfi A single center, intent to treat, trial of long-term efficacy and safety of the Stretta procedure for treatment of medically refractory GERD despite multi-dose PPI medical therapy was conducted. Methods: Beginning August 2000, 109 subjects with documented GERD and/or regurgitation and inadequate symptom control despite minimum bid PPI had an outpatient Stretta procedure via conscious sedation by one doctor (MN), and were followed for 4C years. Patients with normal anatomy, or failed Nissen, large (O3 cm) hiatal hernia, erosive esophagitis, and Barrett’s metaplasia were included. Exclusion criteria were: ASAOIII, collagen vascular disease, stricture, or achalasia. Baseline on/off meds and follow-up 6, 12, 24, 36, 48 months GERD-HRQL scores (0-50), heartburn (0-5), satisfaction (0-5) and medication-use were collected. All statistics performed with SAS or JUMP Statistical Analysis Software. Results: 109 subjects entered study. 13/109 failed to respond. 96 responders followed thru year 4. GERD-HRQL, heartburn, satisfaction, and medication use significantly improved at all follow-up intervals 6, 12, 24, 36, 48 months, (p ! 0.001) and were superior to those achieved on baseline drug therapy. At year 4, patients were divided into 4 medication use categories: 1) No meds, 2) PRN antacids/OTC PPI, 3) Daily PPI QD, 4) PPI BID. 75% of patients showed significant improvement into categories 1 or 2 (p ! 0.05). In all parameters, no significant difference between patient scores at baseline on or off meds was noted. A comparative analysis between patients with (33) and without (76) erosive esophagitis showed significant improvement in both groups with no difference between groups, with durability of results maintained to 4 years without statistical difference between the two groups (p O.7). Anatomic differences did not alter success or response to treatment. No acute adverse events or pathological histological changes occurred. Conclusions: 1) The Stretta procedure has a significant positive and sustained effect on medication use, HRQL, satisfaction and GERD symptoms, with durability of response demonstrated at 4 years, 2) The observed improvement was superior to that achieved with escalated baseline antisecretory therapy, and 3) There was no difference in response in patients with variant anatomy such as Nissen fundoplication, hiatal hernia, erosive esophagitis or Barrett’s esophagus.
group B were bedridden (p ! 0.01). NSAIDs users and alcohol consumers were estimated as 18.4%, 15.8% in group A and 25.6%, 19.2% in group B, respectively (p Z n.s). All of the hemorrhagic lesions in group A located in the lower third of the esophagus involving esophago-gastric junction, while in group B 62.8% of hemorrhagic lesions confined to the stomach, and 37.2% were associated with bulbitis. The prevalence of H. pylori infection was significantly lower in group A (29.2%) than in group B (73.6%) (p ! 0.0005). The histology of background gastric mucosa revealed that atrophy, active inflammation, and intestinal metaplasia were found in 36.8%, 31.6%, 5.3% in group A, and 72.9%, 66.1%, 17.7% in group B, respectively (p ! 0.05-0.005). Conclusion: Hemorrhagic esophagitis occurred exclusively in the elderlys who were inpatient or nursed supine for the underlying diseases. Majority with hemorrhagic esophagitis were negative for H. pylori, which suggested a scanty contribution of H. pylori infection to them, although H. pylori infection might have a certain relation to hemorrhagic gastroduodenitis.
Baseline Baseline P Off Meds On Meds 1 year 2 year 3 year 4 year Value Heartburn Score Total Heartburn Score Satisfaction Score Med Score O7 Z PPI BID NZ
3.6 27.8
2.6 20.5
0.9 6.8
0.7 4.6
1.08 6.7
1.18 7.1
P ! 0.001 P ! 0.001
1.4
2.2
3.97
4.4
3.8
3.8
P ! 0.001
8.43
3.62
3.53
4.3
4.1
P ! 0.005
109
108
102
96
S1534 The Prevalence of Helicobacter Pylori Infection in Patients with Acute Hemorrhagic Esophagitis Seiji Kimura, Masanori Tanaka Background and Aims: Acute hemorrhagic esophagitis is recognized as stressinduced mucosal injury and one of the uncommon source of upper gastrointestinal tract bleeding as well as hemorrhagic erosive gastroduodenitis. It has not been discussed whether H. pylori infection influences on these hemorrhagic mucosal lesions. The study aimed to evaluate the prevalence of H. pylori infection between patients with esophagitis and gastroduodenitis. Methods: The study included 116 patients who presented with upper gastrointestinal tract bleeding, and diagnosed as having hemorrhagic esophagitis (group A, n Z 38), or hemorrhagic gastroduodenitis (group B, n Z 78) by emergency esophagogastroduodenoscopy. Their clinicopathological findings, and the status of H. pylori infection were compared with each other group; H. pylori infection was determined by urease test, serology, and histology. Results: Mean age and sex ratio of patients in group A were 72.6Cÿ12.9 yr, range 34-89, and M:F Z 21:17, and those in group B were 63.1Cÿ15.8yr, range 23-84, and M:F Z 45:33, respectively. Elderlys more than 70 yr of age were more predominant in group A (71.1%) than group B (47.4%) (p ! 0.005), although no gender difference was noted. All patients in group A had background diseases such as cerebrovascular disease 31.6%, dementia 21.1%, diabetes 15.8%, ischemic heart disease 10.5%, though 32.1% of patients in group B had no background diseases. 89.5% in group A and 41.0% in group B received institutional care with nursing (p ! 0.0005), and 34.2% in group A and 11.5% in
AB134 GASTROINTESTINAL ENDOSCOPY Volume 63, No. 5 : 2006
S1535 Endoscopic Evaluation of Opportunistic Infections Inpos Renal Transplant Patients Thais G. Mourao, Paula A. Novais, Hanna B. Sa, Perla O. Schulz, Tais G. Andrade, Monica Soldan, Marcia H. Costa, Marilia S. Andrade, Celeste Elia, Cyrla Zaltman Introduction: All pos renal transplant patients need chronic use of immunosuppressive drugs, predisposing to opportunistic infections. Endoscopy is widely employed in the management of these patients with upper GI symptoms, being capable to confirm a suspected diagnosis of opportunist infection. The aim of this study is to evaluate the appropriateness of upper endoscopy in this special group of patients, trying to correlate the endoscopic and clinical features. Methods: A retrospective study enrolling 589 patients submitted to kidney transplant was done at HUCFF-UFRJ, Rio de Janeiro, Brazil, from 12/1994 to 12/2004. Demographic characteristics, prevalence of upper GI endoscopy done, symptoms (epigastric pain,nausea/vomit, upper GI bleeding, dysphagia and fever), endoscopic diagnosis (gastritis, esophagitis and duodenitis) and the histopathological detection of opportunistic infections (CMV, Herpes sp and Candida sp) were recorded. Statistical analysis was done with SPSS 11.0 software, with qui-quadrad test being used to evaluate the associations and 5% was considered acceptable as significance value. Results: From the 589 patients evaluated, 54,1% was female with mean age of 43 yrs (16-69 yrs). The upper GI endoscopy was required in 29,71% of the patients. The most common endoscopic indication was epigastric pain associated or not with others symptoms (49,6%), followed by: upper GI bleeding (18,9%), nausea/vomit (4,8%); dysphagia/odynophagia (4,8%), heartburn (3%), abdominal pain (1,9%), fever (0,4%) and others (8%). Endoscopy was normal in 15,4% of the cases. The endoscopic finding were gastritis (47%), infectious esophagitis (24,4%), reflux esophagitis (17,8%), duodenal peptic ulcer (7,4%) and infectious gastritis (3,3%). CMV was the most prevalent opportunistic detected agent (7,8%) followed by Candida sp (5,6%) and Herpes virus (3,7%). The c2 test was used to evaluate the correlation between epigastric pain and a noninfectious inflammation with a result of 76.116 (p Z 0.003). Considering the association between esophageal symptoms and the detection of infectious esophageal inflammation, the result was 76.341 (p Z 0.002). Conclusion: Among the renal transplant patients with upper GI symptoms, the epigastric pain was the most frequent indication for upper GI endoscopy, with a poor correlation with gastric opportunistic infection. On the contrary, a high correlation was seen between esophageal symptoms and opportunistic agents detected in the esophagus. We concluded that the presence of esophageal symptoms in this special group of patients must be used as an indicative parameter to evaluate opportunistic infections by upper GI endoscopy.
www.giejournal.org