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Esophageal self-expadable metallic stents (SEMS): Results of a national survey regarding practice and techniques
ESOPHAGUS
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LUGOL'S STAINING IMPROVES ENDOSCOPIC DETECTION OF ESOPHAGEAL SO.UAMOUS DYSPLASlA AND CANCER IN HIGHRISK CHINESE PATIENTS. SM Dawsey, DE Fleiseher, GQ Wang, JA Kidwell, B Zhou, and KJ Lewin. National Cancer Institute, Bethesda, MD; Georgetown Univ Medical Center, Washington, DC; Cancer Institute, CAMS, Beijing, China; UCLA Center for the Health Sciences, Los Angeles, CA, BACKGROUND: In previous studies in the high-risk population of Linxian, China, high-grade (moderate + severe) squamous dysplasia (HGD) and invasive squamous cancer (CA) of the esophagus have been associated with endoscopically visible lesions that could be targeted for biopsy. This study asked whether spraying the mucosa with Lugol's iodine solution, which stains normal epithelium brown= but leaves dysplasia and cancer unstained, could improve endoscopic detection and localization of these lesions. METHODS: 223 Linxian adults were endoscoped. All visible lesions were described and photographed before and after staining with 1.2% Lugol's iodine solution. All unstained lesions (USLs) and representative control areas of stained mucosa were biopsied. RESULTS: 253 USLs and 255 control sites were biopsied. 91 biopsy sites contained HGD and 20 contained CA. Before staining, the sensitivity of visible lesions for identifying HGD and CA was 63%, and the specificity was 79%. After staining, the sensitivity of USLs for identifying HGD and CA was 96%, and the specificity was 64%. 100/111 (90%) of the HGD and CA lesions were larger or more clearly defined after staining. The diagnostic lesions in 16/30 (53%) of the patients with moderate dysplasia, 8/34 (24%) of the patients with severe dysplasla, and 0/19 (0%) of the patients with invasive cancer were identified only ~ifter staining. CONCLUSIONS: Lugol's iodine staining improved endoscopic detection and localization of HGD and CA in these patients. This simple technique is highly sensitive for identifying these precursor and early invasive squamous lesions. IMPLICATIONS: Accurate visualization of HGD and CA may allow endoscopic screening o f high-risk individuals and may enable focal endoscopic therapies to eradicate these lesions. Such visualization may also allow endoscopic protocols to accurately evaluate intervention studies that use squamous dysplasia as an intermediate endpoint.
INDICATIONS AND COMPLICATIONS OF ESOPHAGEAL SELFEXPANDABLE METAL STENTS (SEMS): RESULTS OF A NATIONAL SURVEY. B. Dennert, ST Zierer, FC Ramirez. Carl T. Hayden VA Medical Center, Phoenix Arizona. The self-reported complication rates for the available SEMS, are unknown. Objective: To determine the self-reported indications and complications derived from the use of SEMS by community gastroenterologists. Material and Methods: A mini in survey to ASGE members. Results: A total of 3,414 surveys were mailed. Only 212 (6.2%) responded. 60% of these physicians had experience with SEMS 72% percent practiced in a the private setting and 75% had placed _< 3 SEMS at the time of tins survey. A total of 434 SEMS were placed. The indications for SEMS placement are listed l UncoatedC~
Es~[ CA9 I EGI 3 912 CA 6 I 2Extrinsic 2201
TEt FistN t AFailed NA84 4 0 L6kaeNA
Immediate technical complications were as follows: Misplacement Failed Expansion Failed deployment Microvasive (M) 3 10 3 Schneider (S) 4 4 1 Other/NS(O/NS) 14 17 9 Total 21/434 (4.8%) 31/434 (7.1%) 13/434 (3%) Immediate dieations: Chest Pain Bleed Perforation Migration Death M 1 S 13 2 2 1 O/NS 10 1 3 5 1 Total 24 (5.5%) 1 (0.2%) 5 (1.1%) 7 (1.6%) 2 (0.5%) Del; 9lications: Bleed Perf Migrt Death Tumor GERD TEfis Dysph M 1 4 3 6 9 9 S 1 2 8 2 2 2 7 O/NS 1 1 8 21 19 10 2 22 Tot(%) 2(0.5) 2(0.5) 14(3) 32(7) 27(6) 21(5) 4 (1) 38(9) Conclusions: The rate of technical complications varies from 3-7%. Immediate and delayed patient complications are self reported to vary from 0.2%-5.5% and from 0.5 to 9%, respectively.
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ESOPHAGEAL SELF-EXPANDABLE METALLIC STENTS (SEMS): RESULTS OF A NATIONAL SURVEY REGARDING PRACTICE AND TECHNIQUES. B. Deanert, ST Zierer, FC Ramirez. Carl T Hayden VA Medical Center, Phoenix Arizona.
NONINVASIVE DIAGNOSIS OF GASTROESOPHAGEAL INFLAMMATION USING DIPYRIDAMOLE THALLIUM 201 SCANNING BT De Gregorio, MBrian Fennerty, R Wilson. Oregon Health Sciences University, Portland, OR. BACKGROUND: GERD, defined as symptoms or tissue damage resulting from the reflux of gastric contents, is a common medical problem. Approximately 50% of patients with GERD will have evidence of esophagitis on endoscopy. Radiopharmacenticals, (GA 67, Tc 99m pertechnetate), have been used to diagnosis GI pathology in a noninvasive manner. We hypothesized that esophagitis and gastric erosions seen endoscopieally could also be detected using dipyridamole thallium 201 (DT 201) scanning, and if true this could serve as a useful, noninvasive screening test for esophagitis, etc.. METHODS: A pilot study" was undertaken in winch 12 patients underwent EGDs for symptoms of GERD or dyspepsia. A diagnosis of esophngitis required the presence of erosions and gastric erosions were defined as discreet mucosal breaks measuring 1 nun or more. DT 201 scanning was performed the following day on all 12 patients. A standard dose of dipyridamole (0.56mg/kg) was infused followed by a 3 mCu dose of thallium 201. Initial, stress images and reinjection (1 mCu) resting images were obtained using a gamma camera. Images were read by a cardiologist who was blinded to the EGD results. Thallium uptake was graded on a 0 to 3+ scale using the liver uptake as the internal comparative standard (2+ = uptake equal to the liver). Abnormal thallium uptake was defined as 2+ or greater in the area of the esophagus or stomach. RESULTS: Seven females and 5 males (mean age of 41 years old; range 25-60) were studied. Eight patients were on histamine-2 receptor antagonists and none were on proton pump inhibitors, or promotility agents. Five patients had endoscopic esophagitis with 4 of these 5 having positive thallium scans. Seven patients had no evidence of erosive esophagitis, yet 3 of 7 had positive thallium scans. Sens., spec., pos. and neg predictive values for DT 201 to detect esophagitis were 80%, 57%, 57%, and 80%. With regard to the stomach, 3 patients had gastric erosions and had positive thallium scans. Six of the remaining 9 patients without gastric erosions had positive thallium scans. Sens., spec., pos. and neg predictive value for DT 201 to detect gastric erosions were 100%, 33%, 33%, and 100%. CONCLUSIONS: DT 201 has poor predictive value for identifying esophagitis or clinically significant gastric pathology, therefore is not a useful noninvasive screening test for these diseases. Additionally, the cost of radiopharmaceuticals requires that sens/spec equal that of endoscopy ha order for it to be clinicallyvaluable.
SEMS have changed the management of malignant dysphagia. The magnitude of SEMS use in the community, and the clinical outcomes is unknown. Objective: To determine the reasons for SEMS selection and practice techniques for their placement in the gastroenterology community. Material and Methods: A survey was mailed to members of the ASGE Results: Of 3414 surveys mailed, only 212 responded (62%). 128 physicians had experience with the placement of SEMS (60%) and the remaining 84 (40%) did not. Self-reported practice settings for the users were: private 72%, academic 24%, and VAMC 4%. These figures did not differ from the non-user group. A total of 434 SEMS were placed. 75% of users had placed< 3 SEMS. Dilation before SEMS OTW TTS 83 (65%) 40 (31%)
Guidance for Deployment Endosc (E) alone Fluorosc(F) alone 2 (2%) 19 (15%)
Verification Patency/Position Scope Thru SEMS [ 1mmed X-ray [ Ba Sw same day 78 (61%) ] 46 (36%) I 14 (11%)
E+F 106 (83%)
Ba Sw next day 24 (19%)
Patients were discharged home the same day by 20%, and the next day' by 36% of respondents. The choice of SEMS was based on: perceived ease of placement 71 (55%); availability for coated form 62 (48%); availability of desired length 36 (28%); documented efficacy in clinical studies 27 (21%); company advertisement 23 (18%); advise from fellow physician 22 (17%); cost difference 20 (16%); negative past experience 16 (125%); perceived difference in stent strength 11 (8.6%). The SEMS chosen were: Ultraflex: 184 (42%); Wallstent: 183 (42%); Gianturco: 40 (9%); Endocoil: 25 (6%). Forty-six percent (59) physicians considered the placement of SEMS as the first line therapy for dysphagia in unresectable malignancy. Conclusions: SEMS are increasingly being placed as a first line therapy for malignant dysphagia. Self reported techniques and stent choices vary widely. Practice guidelines on the use of SEMS may be helpful.
VOLUME 43, NO. 4, 1996
GASTROINTESTINAL ENDOSCOPY
333
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LUGOL'S STAINING IMPROVES ENDOSCOPIC DETECTION OF ESOPHAGEAL SO.UAMOUS DYSPLASlA AND CANCER IN HIGHRISK CHINESE PATIENTS. SM Dawsey, DE Fleiseher, GQ Wang, JA Kidwell, B Zhou, and KJ Lewin. National Cancer Institute, Bethesda, MD; Georgetown Univ Medical Center, Washington, DC; Cancer Institute, CAMS, Beijing, China; UCLA Center for the Health Sciences, Los Angeles, CA, BACKGROUND: In previous studies in the high-risk population of Linxian, China, high-grade (moderate + severe) squamous dysplasia (HGD) and invasive squamous cancer (CA) of the esophagus have been associated with endoscopically visible lesions that could be targeted for biopsy. This study asked whether spraying the mucosa with Lugol's iodine solution, which stains normal epithelium brown= but leaves dysplasia and cancer unstained, could improve endoscopic detection and localization of these lesions. METHODS: 223 Linxian adults were endoscoped. All visible lesions were described and photographed before and after staining with 1.2% Lugol's iodine solution. All unstained lesions (USLs) and representative control areas of stained mucosa were biopsied. RESULTS: 253 USLs and 255 control sites were biopsied. 91 biopsy sites contained HGD and 20 contained CA. Before staining, the sensitivity of visible lesions for identifying HGD and CA was 63%, and the specificity was 79%. After staining, the sensitivity of USLs for identifying HGD and CA was 96%, and the specificity was 64%. 100/111 (90%) of the HGD and CA lesions were larger or more clearly defined after staining. The diagnostic lesions in 16/30 (53%) of the patients with moderate dysplasia, 8/34 (24%) of the patients with severe dysplasla, and 0/19 (0%) of the patients with invasive cancer were identified only ~ifter staining. CONCLUSIONS: Lugol's iodine staining improved endoscopic detection and localization of HGD and CA in these patients. This simple technique is highly sensitive for identifying these precursor and early invasive squamous lesions. IMPLICATIONS: Accurate visualization of HGD and CA may allow endoscopic screening o f high-risk individuals and may enable focal endoscopic therapies to eradicate these lesions. Such visualization may also allow endoscopic protocols to accurately evaluate intervention studies that use squamous dysplasia as an intermediate endpoint.
INDICATIONS AND COMPLICATIONS OF ESOPHAGEAL SELFEXPANDABLE METAL STENTS (SEMS): RESULTS OF A NATIONAL SURVEY. B. Dennert, ST Zierer, FC Ramirez. Carl T. Hayden VA Medical Center, Phoenix Arizona. The self-reported complication rates for the available SEMS, are unknown. Objective: To determine the self-reported indications and complications derived from the use of SEMS by community gastroenterologists. Material and Methods: A mini in survey to ASGE members. Results: A total of 3,414 surveys were mailed. Only 212 (6.2%) responded. 60% of these physicians had experience with SEMS 72% percent practiced in a the private setting and 75% had placed _< 3 SEMS at the time of tins survey. A total of 434 SEMS were placed. The indications for SEMS placement are listed l UncoatedC~
Es~[ CA9 I EGI 3 912 CA 6 I 2Extrinsic 2201
TEt FistN t AFailed NA84 4 0 L6kaeNA
Immediate technical complications were as follows: Misplacement Failed Expansion Failed deployment Microvasive (M) 3 10 3 Schneider (S) 4 4 1 Other/NS(O/NS) 14 17 9 Total 21/434 (4.8%) 31/434 (7.1%) 13/434 (3%) Immediate dieations: Chest Pain Bleed Perforation Migration Death M 1 S 13 2 2 1 O/NS 10 1 3 5 1 Total 24 (5.5%) 1 (0.2%) 5 (1.1%) 7 (1.6%) 2 (0.5%) Del; 9lications: Bleed Perf Migrt Death Tumor GERD TEfis Dysph M 1 4 3 6 9 9 S 1 2 8 2 2 2 7 O/NS 1 1 8 21 19 10 2 22 Tot(%) 2(0.5) 2(0.5) 14(3) 32(7) 27(6) 21(5) 4 (1) 38(9) Conclusions: The rate of technical complications varies from 3-7%. Immediate and delayed patient complications are self reported to vary from 0.2%-5.5% and from 0.5 to 9%, respectively.
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ESOPHAGEAL SELF-EXPANDABLE METALLIC STENTS (SEMS): RESULTS OF A NATIONAL SURVEY REGARDING PRACTICE AND TECHNIQUES. B. Deanert, ST Zierer, FC Ramirez. Carl T Hayden VA Medical Center, Phoenix Arizona.
NONINVASIVE DIAGNOSIS OF GASTROESOPHAGEAL INFLAMMATION USING DIPYRIDAMOLE THALLIUM 201 SCANNING BT De Gregorio, MBrian Fennerty, R Wilson. Oregon Health Sciences University, Portland, OR. BACKGROUND: GERD, defined as symptoms or tissue damage resulting from the reflux of gastric contents, is a common medical problem. Approximately 50% of patients with GERD will have evidence of esophagitis on endoscopy. Radiopharmacenticals, (GA 67, Tc 99m pertechnetate), have been used to diagnosis GI pathology in a noninvasive manner. We hypothesized that esophagitis and gastric erosions seen endoscopieally could also be detected using dipyridamole thallium 201 (DT 201) scanning, and if true this could serve as a useful, noninvasive screening test for esophagitis, etc.. METHODS: A pilot study" was undertaken in winch 12 patients underwent EGDs for symptoms of GERD or dyspepsia. A diagnosis of esophngitis required the presence of erosions and gastric erosions were defined as discreet mucosal breaks measuring 1 nun or more. DT 201 scanning was performed the following day on all 12 patients. A standard dose of dipyridamole (0.56mg/kg) was infused followed by a 3 mCu dose of thallium 201. Initial, stress images and reinjection (1 mCu) resting images were obtained using a gamma camera. Images were read by a cardiologist who was blinded to the EGD results. Thallium uptake was graded on a 0 to 3+ scale using the liver uptake as the internal comparative standard (2+ = uptake equal to the liver). Abnormal thallium uptake was defined as 2+ or greater in the area of the esophagus or stomach. RESULTS: Seven females and 5 males (mean age of 41 years old; range 25-60) were studied. Eight patients were on histamine-2 receptor antagonists and none were on proton pump inhibitors, or promotility agents. Five patients had endoscopic esophagitis with 4 of these 5 having positive thallium scans. Seven patients had no evidence of erosive esophagitis, yet 3 of 7 had positive thallium scans. Sens., spec., pos. and neg predictive values for DT 201 to detect esophagitis were 80%, 57%, 57%, and 80%. With regard to the stomach, 3 patients had gastric erosions and had positive thallium scans. Six of the remaining 9 patients without gastric erosions had positive thallium scans. Sens., spec., pos. and neg predictive value for DT 201 to detect gastric erosions were 100%, 33%, 33%, and 100%. CONCLUSIONS: DT 201 has poor predictive value for identifying esophagitis or clinically significant gastric pathology, therefore is not a useful noninvasive screening test for these diseases. Additionally, the cost of radiopharmaceuticals requires that sens/spec equal that of endoscopy ha order for it to be clinicallyvaluable.
SEMS have changed the management of malignant dysphagia. The magnitude of SEMS use in the community, and the clinical outcomes is unknown. Objective: To determine the reasons for SEMS selection and practice techniques for their placement in the gastroenterology community. Material and Methods: A survey was mailed to members of the ASGE Results: Of 3414 surveys mailed, only 212 responded (62%). 128 physicians had experience with the placement of SEMS (60%) and the remaining 84 (40%) did not. Self-reported practice settings for the users were: private 72%, academic 24%, and VAMC 4%. These figures did not differ from the non-user group. A total of 434 SEMS were placed. 75% of users had placed< 3 SEMS. Dilation before SEMS OTW TTS 83 (65%) 40 (31%)
Guidance for Deployment Endosc (E) alone Fluorosc(F) alone 2 (2%) 19 (15%)
Verification Patency/Position Scope Thru SEMS [ 1mmed X-ray [ Ba Sw same day 78 (61%) ] 46 (36%) I 14 (11%)
E+F 106 (83%)
Ba Sw next day 24 (19%)
Patients were discharged home the same day by 20%, and the next day' by 36% of respondents. The choice of SEMS was based on: perceived ease of placement 71 (55%); availability for coated form 62 (48%); availability of desired length 36 (28%); documented efficacy in clinical studies 27 (21%); company advertisement 23 (18%); advise from fellow physician 22 (17%); cost difference 20 (16%); negative past experience 16 (125%); perceived difference in stent strength 11 (8.6%). The SEMS chosen were: Ultraflex: 184 (42%); Wallstent: 183 (42%); Gianturco: 40 (9%); Endocoil: 25 (6%). Forty-six percent (59) physicians considered the placement of SEMS as the first line therapy for dysphagia in unresectable malignancy. Conclusions: SEMS are increasingly being placed as a first line therapy for malignant dysphagia. Self reported techniques and stent choices vary widely. Practice guidelines on the use of SEMS may be helpful.
VOLUME 43, NO. 4, 1996
GASTROINTESTINAL ENDOSCOPY
333