Evaluation of endoscopic mucosal resection for treatment of early gastric cancer: Assessment of post-operative complications

*4334 VARIABILITY IN THE DIAGNOSTIC YIELD OF HELICOBACTER pYLORI TESTING IN ACUTE U P P E R GASTROINTESTINAL (GI) BLEEDING: IS A CHANGE IN APPROACH INDICATED? Douglas C. Walsh, Chandra Prakash, Marc Levin, Gary R. Zuckerman, Washington Univ, St. Louis, MO BACKGROUND: The yield of diagnostic testing for Helicobacter priori in patients presenting with acute upper GI bleeding has been demonstrated to be lower than in patients without bleeding. In order to determine the best test or tests to use in this setting, we analyzed our data on H. priori testing in patients with upper GI bleeding. METHODS: Patients with peptic ulcers presenting with acute upper GI bleeding were identified from a prospectively acquired database incorporating patient demographics, clinical presentation, medication history, endoscopy findings, and results of other relevant clinical investigations, at the endoscopy center, Washington University School of Medicine. The results of rapid urease tests, histology and serum antibody tests were extracted from the database. RESULTS: Over a 3-year period, 281 patients (127F/154M; age 64 ±1 yr) presented with acute upper GI bleeding in the setting of peptic ulcer disease, all of which had testing for the presence of/-/, pylori. Eighty-five patients (30.2%) had at least one test positive for H. priori. The diagnostic yield of the rapid urease test was 21.4% (21/98 positive), histology 16.7% (2/12 positive) and serum antibody test 37.7% (23/61 positive). Overall, the diagnostic yield improved to 42.9% when the rapid urease test was combined with serum antibody testing (21 patients), and to 61.3% when all three tests were performed (31 patients) (p<0.0001 across groups). Within the subset of patients testing positive for H. pylori (n=85), serum antibody testing had the best diagnostic yield (43/51 positive, 84.3%) and histology the worst (20/33 positive, 60.6%); the rapid urease test was positive in 44/61 (72.1%) (p=0.05 across groups). Projecting the diagnostic yield of using all three tests to the entire study population, assuming similar prevalence of H. pylori, 87 additional patients could have tested positive if all three tests had been uniformly performed. CONCLUSIONS: (1) The diagnostic yield of H. priori testing in our patient population with upper GI bleeding is low. (2) Non-invasive tests appear to have a better yield compared to tests using endoscopic biopsy. (3) However, the sensitivity of H. priori testing can be significantly improved by obtaining all three tests (rapid urease, histology and serum antibody test) on every patient with upper GI bleeding. (4) Future studies will need to evaluate the role of urea breath tests at presentation in patients with upper GI bleeding. *4335 ENDOENTEROCLYSIS: A NEW TECHN QUE FOR SMALL BOWEL EVALUATION Michel Ghastine, Adnan Said, Andrew J. Taylor, Mark Reichelderfer, Univ of Wisconsin Hosp and Clinics, Madison, WI Background: Complete small bowel (SB) evaluation for SB problems not amenable to diagnosis with a routine SB series remains challenging (occult GI bleeding, etc). Three available techniques include push enteroscopy (ES) (often successful only to mid jejunum and usually requiring overtube placement), enteroclysis (EC) (occasional poor patient acceptance related to tube placement), and pull ES (visualizes the entire small intestine but takes all day with only one SB visualization on pullback). The first two are often combined but the combination is logistically complex and time consuming. We therefore investigated a new method for combining ES and EC. Methods/Results: Three patients were referred for ES for occult GI bleeding and consented for ES and EC. Standard push ES using a Pentax enteroscope was performed with the instrument passed to the mid to distal jejunum in all three cases (no abnormalities detected on pullback). We then proceeded with enteroclysis after readvancing the endoscope and injecting standard contrast agents through the suction channel (gastrograffin for one and barium and methylcellulose for the other two - 300 cc of contrast followed by 700 cc of methylcellulose). We used insuffiation of air to helped propel the contrast forward, and intravenous metoclopramide in the first two patients, but surprisingly reflux back into the stomach remained a significant problem (no occlusion balloons were used as none are commercially available). In the first patient, we deflated the stomach with a NG tube and continued with less reflux. No problems with sedation or with the presence of the enteroscope occurred. The exams all took less than 30 minutes to accomplish with adequate images obtained in two patients and excellent images in one - all were negative for pathology (see attached image). Conclusion: We conclude that EEC is technically feasible.The benefits of this approach include the ability to evaluate the full length of the small bowel with one synchronous exam; in addition, the EC was improved by an enhanced ability to distend the SB. In addition, patient acceptance was improved. The choice of contrast agent (barium with methylcellulose) and small intestinal motility are key determinants in the safety and success of this procedure, as well as the clear need for a through-the-scope injection]occlusion balloon. Further studies are underway.

V O L U M E 53, NO. 5, 2001

:,,¢ )/

*4336 DIATHERMY ELECTROCOAGULATION F O R BLEEDING GASTRIC VARICES (DEPT.OF GASTROENTEROLOGY.PGMI/ HIVIC,PESHAWAR) Mohammad S. Shah, Ijaz M. Khan, Ikramullah Khan, Khalid Hameed SR, PGMI/HMC, Peshawar Pakistan Variceal bleed poses a lethal complication in cirrhosis with portal hypertension.Injection selerotherapy remains the mainstay procedure for initial control of bleeding oesophgeal varices.Band llgation has its advocates for oesphgeal variceal bleeds while TIPSS, a procedure to reduce portal pressure,is not available in many centres. Gastric variceal bleeds continue to evade most available therapeutic procedures for effective control of bleeding. At our centre,we evolved the procedure of diathermy electrocoagulation for effective control of gastricvariceal bleeds.The PSD-2E electrosurgical unit has the coagulation mode set at 1.5my and the CD-3L diathermy probe makes contact with the bleeding varix for instant control of bleeding.The redesigned CD-3L AE has the added advantage to irrigate and aspirate thus giving you a clear working field. A total No.324 bleeders,followed up for 10 years,showed a 97% success rate with no evidence of any significant complication.Coagulation was achieved,in the majority,in 1-2 sessions.Rebleeding was less frequent and mortality recorded in the followup was a total of 9 deaths[2.76%]. CONCLUSION:Diathermy Electrocoagnlatien is the recommended treatment of choice for bleeding gastric varices. *4337 EVALUATION OF ENDOSCOPIC MUCOSAL RESECTION FOR TREATMENT OF EARLY GASTRIC CANCER: ASSESSMENT OF POST-OPERATIVE COMPLICATIONS Atsushi Itani, Masatsugu Shiba, Makiko Taguchi, Toshihiro Okazaki, Tomoko Wada, Ai Montani, Hirohisa Maehida, Toshiyuki Uehida, Yasuhiro Fujiwara, Kazuhide Higuchi, Tetsuo Arakawa, Osaka City Univ Medical Sch, Osaka Japan BACKGROUND AND AIMS: In recent years, endoscopic mucosal resection (EMR) of gastric intramucosal cancer has become an increasingly popular alternative to surgical treatment. However, major complications may be encountered with EMR such as bleeding and perforation. By far, the most frequently reported complication in the literature is bleeding. In this report, we analysed retrospectively the incidence of bleeding in Japanese patients who underwent EMR in our unit and whether it was associated with any of the following factors: the technique of EMR used, the location of tumor in the stomach, its endoscopic type, diameter, and invasion depth. METHODS: Between April 1991 and December 1997, we performed EMR, either by strip biopsy (SB) using double-channel endoscope or by endoscopic aspiration mucosectomy (EAM), for 320 patients with early gastric cancer and borderline adenoma. Their mean age was 65.84±8.93 years. For purpose of analysis; the stomach was divided into 3 regions: 1) antrum and angle, 2) lower and middle body, and 3) upper body and fundus. Endoscopically, the lesions were divided into an elevated type (306 lesions) and a fiat or depressed type (46 lesions). RESULTS: Three hundred fifty two tumors were resected, 187 from the first gastric region, 139 from the second, and 26 from the third region. The mean diameter of excised tumors was 12.50±7.12 mm. Regarding the invasion depth, 330 lesions were intramucosal and 22 invaded the submucosal layer. Incidence of bleeding was not related to the location of the tumor, its diameter or invasion depth. However, it was significantly related to the type of the technique used and the endoscopic type of the tumor. Highest incidence of bleeding was observed with fiat or depressed tumors (p<0.001 in comparison with the elevated type) and with those treated by EAM (40/145 lesions or 27.6%, p<0.05 in comparsian with SB). CONCLUSIONS: EMR performed by SB technique has lower bleeding incidence than EAM. Highest rate of bleeding occurred with depressed or fiat type when compared with the elevated type.

GASTROINTESTINAL

ENDOSCOPY

AB205