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Herpes Simplex Virus Esophagitis in Immunocompetent Patients: A Case Series from Rhode Island Hospital
Abstracts
referred for endoscopic treatment with a modified Tygon plastic stent during the period from November 1997 to June 2007 were reviewed. Tygon plastic stents with a diameter ranging from 9-14 mm were individually tailored according to the location of the leaks. After endoscopic placement of a guidewire, the stent was inserted over a bougie without fluoroscopic monitoring. To prevent distal migration, a 7Fr Teflon catheter was attached to the proximal end of the stent and looped around the ear before being fixated with adhesive tape. Results: A total of 40 patients (80% male; mean age 63.5 years) with upper GI anastomotic leaks (post-esophagectomy: 22.5%; post-gastrectomy: 35%; post-esophago-gastrectomy: 37.5%; chronic anastomotic fistula: 5%) were treated with a modified Tygon plastic stent with a mean duration of 32 days (range: 2 - 209) after surgery. Forty percent of these patients had previous unsuccessful treatment with surgery (35%) or endoscopic fibrin glue injection (5%). Stent insertion was technically successful in all patients without any procedure related complications. After stent placement, 30% of patients died from other postoperative complications and severe underlying co-morbidities before resolution of the leaks. Successful resolution of leaks occurred in 96.4% of the remaining cases after stent placement, and the stents were subsequently removed easily without the need for endoscopy after a mean duration of 39 days (range: 17 - 130). Stent dislocation occurred in 15% of cases but successful reinsertion was possible in all instances. No complications occurred after stent placement. Conclusions: Endoscopic temporary placement of a modified Tygon plastic stent is a very effective and safe method for management of upper GI anastomotic leaks.
hospitalized with symptoms directly attributable to HSV esophagitis. The remaining patients (44%) developed symptoms after being admitted for a different medical condition. Oropharyngeal lesions were reported in only one case. Endoscopy revealed scattered superficial esophageal ulceration (88%), friable mucosa (56%), and white exudates (56%) predominantly involving the mid-to-distal esophagus (67%) or entire length of the esophagus (33%). Diffuse candidiasis was reported as the suspected endoscopic diagnosis in 44% of cases. The final diagnosis in all cases was made by histopathology, with or without immunohistochemistry. Candida coinfection was present in one case. Patients were treated with antiviral therapy (56%) or acid suppression therapy (44%). 60% of patients on antiviral therapy reported significant improvement in symptoms within 48hrs of initiating therapy. All patients confirmed resolution of symptoms within two weeks of diagnosis and no recurrence was reported. Conclusion: HSV esophagitis is uncommon in immunocompetent patients. This case series identified elderly women to be at the greatest risk for developing HSV esophagitis, although formerly reported as a condition predominantly affecting young women. Symptoms develop acutely and consist primarily of heartburn or odynophagia. Scattered superficial ulcerations involving the mid-to-distal esophagus are suggestive of HSV esophagitis. Biopsy specimens should be submitted for histology to confirm diagnosis, as macroscopic findings may mimic esophageal candidiasis. HSV esophagitis is a self-limited infection. It is unknown if antiviral therapy reduces the risk of recurrent infection.
M1366 Silicone-Covered Self-Expanding Polyester Stents for the Closure of Thoracic Anastomotic Leaks After Esophagectomy Satish Nagula, Mark A. Schattner, Manjit S. Bains, Hans Gerdes
M1368 Upper Gastrointestinal Symptoms and Associated Disorders in Morbidly Obese Patients - A Prospective Study Manish Arora, Sudhir K. Dutta, Kireet Agrawal, Hany Bashandy, Alejandro Gandsas
Background: Anastomotic leaks are a major source of morbidity and mortality after esophagectomy, with an incidence of 4-17%, and associated mortality of up to 45%. Conservative therapy of prolonged leaks (O2 weeks) has a success rate of 60%, requiring an average of 13 weeks for closure (Bueno JT et al, GIE 2003). Prior studies on the use of a silicone-covered self-expanding polyester stent (Polyflex, Boston Scientific, Natick, MA) for leak closure illustrated a 90-100% success rate, with a low rate of stent migration. This report details our experience with the Polyflex stent for leak closure after esophagectomy. Methods: Records for all patients at Memorial Sloan-Kettering Cancer Center who underwent Polyflex stent placement for the treatment of a thoracic anastomotic leak after esophagectomy were reviewed. Results: Twelve patients had an esophageal Polyflex stent placed for the treatment of anastomotic leaks (10 male, median age 64 years). Major leaks were identified by barium esophagram on 10 patients, by CT scan on 2 patients. All patients initially received conservative therapy; median time to stent placement was 25 days. Endoscopy revealed disruption of the esophagogastric anastomosis in each patient; stent placement was technically successful in all patients (7 patients with a 21-25 mm diameter stent, 5 with an 18-23 mm stent). Leaks resolved in 7 patients (58%) as seen on subsequent esophagography or endoscopy (time to closure ranged from 2 days to 6 weeks). Two patients had stents placed 3 weeks prior to abstract submission, and the leaks appear persistent yet significantly improved. Three patients (25%) had persistent leaks after 7 weeks; two had multiple stent migrations despite endoscopic repositioning, and one had the stent in place for 1 year (removal delayed due to treatment of metastases), eventually dying after a massive upper GI hemorrhage caused by stent erosion into the vertebral artery. Stent migration occurred in 9 patients (75%); all stents less than 25 mm in diameter (n Z 5) migrated. Two patients (17%) died from complications related to the anastomotic leak. Conclusion: Polyflex stent placement is a useful adjunct in the treatment of anastomotic leaks after esophagectomy, although with lower efficacy than previously reported. Migration was a common event, limiting the utility of the Polyflex stent. Rates of migration may be minimized with the use of larger diameter stents (25 mm), but improvements in stent design are needed to improve the efficacy and reduce the migration rate. We recommend that Polyflex stents for anastomotic leaks are removed within 3 months of insertion to avoid potential erosion through the wall of the GI tract.
M1367 Herpes Simplex Virus Esophagitis in Immunocompetent Patients: A Case Series from Rhode Island Hospital Erich Vorlop, Deepak Agrawal, Sripathi R. Kethu Objective: Herpes simplex virus (HSV) esophagitis is rare in immunocompetent patients, with only 36 reported adult cases to date. The aim of this case series is to identify characteristics of immunocompetent patients at risk of developing HSV esophagitis, study the natural progression, and evaluate the efficacy of antiviral treatment. Methods: A retrospective cohort study was performed on all consecutive HSV esophagitis cases diagnosed from 2003-to-2007. Twenty-six cases were initially identified with histopathology proven HSV esophagitis. Immunocompromised patients due to immunomodulator therapy, critical illness, poorly controlled diabetes mellitus, autoimmune disease, cancer, or human immunodeficiency virus infection were excluded from the study. Results: A Total of nine cases were identified. The age of patients ranging from 25-90 (mean:72). The female/male ratio was 3.5/1. Presenting symptoms included heartburn (56%), odynophagia (44%), melena (33%), and none reported fever. The majority of patients (56%) were
AB192 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
Objective: To prospectively evaluate the frequency of upper gastrointestinal symptoms and associated disorders in morbidly obese patients with endoscopy and histology prior to their gastric bypass surgery in comparison to age and sex matched control non-obese subjects. Methods: All patients who were scheduled to undergo laparoscopic gastric bypass for treatment of morbid obesity (BMIO40) during one year period (n Z 101) were included in the study. Age and sex matched non-obese patients who were seen in the medical clinics during the study period were enrolled as control subjects. The demographic data, total body weight, body mass index, gastrointestinal symptoms were recorded and the results of upper endoscopy and histology were tabulated. Endoscopic documentation of hiatal hernia, esophagitis, gastritis, gastric polyps and peptic ulcer disease was also noted along with the histologic findings of the mucosal biopsies from the upper gastrointestinal tract. Results: The prevalence of heartburn as a symptom was significantly higher (P ! 0.05) in the morbidly obese patients (32.6%) as compared to the control group (18.8%). Endoscopically, the prevalence of hiatal hernia was also significantly higher (P ! 0.05) in the morbidly obese group (38.6%) as compared to the control group (13.8%). Similarly the frequency of endoscopically and histologically identified gastritis was significantly higher (P ! 0.01) in the morbidly obese patient group. However, the frequency of histologically identified H. pylori was not statistically different in the two groups. Conclusion: These observations suggest a significant increase in the frequency of heartburn, hiatal hernia, and histologically identified gastritis in morbidly obese patients. Table 1. Comparison of upper GI symptoms among the study and control group.
Symptoms
Study Group N Z 101 (%)
Heartburn 33 Regurgitation 19 Dysphagia 3 Upper abdominal discomfort 19 Bloating and Belching 27 Nausea 14 Duodenitis 4 )p ! 0.05 statistically significant.
(32.6) (18.8) (2.9) (18.8) (26.7) (13.8) (3.9)
Control Group N Z 101 (%) 19 12 3 16 17 12 5
(18.8) (11.8) (2.9) (15.8) (16.8) (11.8) (4.9)
Statistical significance (p value) ) 0.02 0.16 1.0 0.5 0.06 0.67 p Z 0.72
Table 2. Observed findings during upper Endoscopy.
Observed Findings
Study group N Z 101 (%)
Control Group N Z 101 (%)
Hiatal hernia Esophagitis Gastritis Acute on chronic Gastritis-Chronic Gastric polyps PUD Duodenitis
39 9 9 15 5 3 4
14 (13.8) 7 (6.9) 12 (11.8)
(38.6) (8.9) (8.9) (14.8) (4.9) (2.9) (3.9)
2 (1.9) 4 (3.9) 5 (4.9)
Statistical significance (p value) ) p ! 0.001 0.59 ) 0.02 0.24 0.69 0.72
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referred for endoscopic treatment with a modified Tygon plastic stent during the period from November 1997 to June 2007 were reviewed. Tygon plastic stents with a diameter ranging from 9-14 mm were individually tailored according to the location of the leaks. After endoscopic placement of a guidewire, the stent was inserted over a bougie without fluoroscopic monitoring. To prevent distal migration, a 7Fr Teflon catheter was attached to the proximal end of the stent and looped around the ear before being fixated with adhesive tape. Results: A total of 40 patients (80% male; mean age 63.5 years) with upper GI anastomotic leaks (post-esophagectomy: 22.5%; post-gastrectomy: 35%; post-esophago-gastrectomy: 37.5%; chronic anastomotic fistula: 5%) were treated with a modified Tygon plastic stent with a mean duration of 32 days (range: 2 - 209) after surgery. Forty percent of these patients had previous unsuccessful treatment with surgery (35%) or endoscopic fibrin glue injection (5%). Stent insertion was technically successful in all patients without any procedure related complications. After stent placement, 30% of patients died from other postoperative complications and severe underlying co-morbidities before resolution of the leaks. Successful resolution of leaks occurred in 96.4% of the remaining cases after stent placement, and the stents were subsequently removed easily without the need for endoscopy after a mean duration of 39 days (range: 17 - 130). Stent dislocation occurred in 15% of cases but successful reinsertion was possible in all instances. No complications occurred after stent placement. Conclusions: Endoscopic temporary placement of a modified Tygon plastic stent is a very effective and safe method for management of upper GI anastomotic leaks.
hospitalized with symptoms directly attributable to HSV esophagitis. The remaining patients (44%) developed symptoms after being admitted for a different medical condition. Oropharyngeal lesions were reported in only one case. Endoscopy revealed scattered superficial esophageal ulceration (88%), friable mucosa (56%), and white exudates (56%) predominantly involving the mid-to-distal esophagus (67%) or entire length of the esophagus (33%). Diffuse candidiasis was reported as the suspected endoscopic diagnosis in 44% of cases. The final diagnosis in all cases was made by histopathology, with or without immunohistochemistry. Candida coinfection was present in one case. Patients were treated with antiviral therapy (56%) or acid suppression therapy (44%). 60% of patients on antiviral therapy reported significant improvement in symptoms within 48hrs of initiating therapy. All patients confirmed resolution of symptoms within two weeks of diagnosis and no recurrence was reported. Conclusion: HSV esophagitis is uncommon in immunocompetent patients. This case series identified elderly women to be at the greatest risk for developing HSV esophagitis, although formerly reported as a condition predominantly affecting young women. Symptoms develop acutely and consist primarily of heartburn or odynophagia. Scattered superficial ulcerations involving the mid-to-distal esophagus are suggestive of HSV esophagitis. Biopsy specimens should be submitted for histology to confirm diagnosis, as macroscopic findings may mimic esophageal candidiasis. HSV esophagitis is a self-limited infection. It is unknown if antiviral therapy reduces the risk of recurrent infection.
M1366 Silicone-Covered Self-Expanding Polyester Stents for the Closure of Thoracic Anastomotic Leaks After Esophagectomy Satish Nagula, Mark A. Schattner, Manjit S. Bains, Hans Gerdes
M1368 Upper Gastrointestinal Symptoms and Associated Disorders in Morbidly Obese Patients - A Prospective Study Manish Arora, Sudhir K. Dutta, Kireet Agrawal, Hany Bashandy, Alejandro Gandsas
Background: Anastomotic leaks are a major source of morbidity and mortality after esophagectomy, with an incidence of 4-17%, and associated mortality of up to 45%. Conservative therapy of prolonged leaks (O2 weeks) has a success rate of 60%, requiring an average of 13 weeks for closure (Bueno JT et al, GIE 2003). Prior studies on the use of a silicone-covered self-expanding polyester stent (Polyflex, Boston Scientific, Natick, MA) for leak closure illustrated a 90-100% success rate, with a low rate of stent migration. This report details our experience with the Polyflex stent for leak closure after esophagectomy. Methods: Records for all patients at Memorial Sloan-Kettering Cancer Center who underwent Polyflex stent placement for the treatment of a thoracic anastomotic leak after esophagectomy were reviewed. Results: Twelve patients had an esophageal Polyflex stent placed for the treatment of anastomotic leaks (10 male, median age 64 years). Major leaks were identified by barium esophagram on 10 patients, by CT scan on 2 patients. All patients initially received conservative therapy; median time to stent placement was 25 days. Endoscopy revealed disruption of the esophagogastric anastomosis in each patient; stent placement was technically successful in all patients (7 patients with a 21-25 mm diameter stent, 5 with an 18-23 mm stent). Leaks resolved in 7 patients (58%) as seen on subsequent esophagography or endoscopy (time to closure ranged from 2 days to 6 weeks). Two patients had stents placed 3 weeks prior to abstract submission, and the leaks appear persistent yet significantly improved. Three patients (25%) had persistent leaks after 7 weeks; two had multiple stent migrations despite endoscopic repositioning, and one had the stent in place for 1 year (removal delayed due to treatment of metastases), eventually dying after a massive upper GI hemorrhage caused by stent erosion into the vertebral artery. Stent migration occurred in 9 patients (75%); all stents less than 25 mm in diameter (n Z 5) migrated. Two patients (17%) died from complications related to the anastomotic leak. Conclusion: Polyflex stent placement is a useful adjunct in the treatment of anastomotic leaks after esophagectomy, although with lower efficacy than previously reported. Migration was a common event, limiting the utility of the Polyflex stent. Rates of migration may be minimized with the use of larger diameter stents (25 mm), but improvements in stent design are needed to improve the efficacy and reduce the migration rate. We recommend that Polyflex stents for anastomotic leaks are removed within 3 months of insertion to avoid potential erosion through the wall of the GI tract.
M1367 Herpes Simplex Virus Esophagitis in Immunocompetent Patients: A Case Series from Rhode Island Hospital Erich Vorlop, Deepak Agrawal, Sripathi R. Kethu Objective: Herpes simplex virus (HSV) esophagitis is rare in immunocompetent patients, with only 36 reported adult cases to date. The aim of this case series is to identify characteristics of immunocompetent patients at risk of developing HSV esophagitis, study the natural progression, and evaluate the efficacy of antiviral treatment. Methods: A retrospective cohort study was performed on all consecutive HSV esophagitis cases diagnosed from 2003-to-2007. Twenty-six cases were initially identified with histopathology proven HSV esophagitis. Immunocompromised patients due to immunomodulator therapy, critical illness, poorly controlled diabetes mellitus, autoimmune disease, cancer, or human immunodeficiency virus infection were excluded from the study. Results: A Total of nine cases were identified. The age of patients ranging from 25-90 (mean:72). The female/male ratio was 3.5/1. Presenting symptoms included heartburn (56%), odynophagia (44%), melena (33%), and none reported fever. The majority of patients (56%) were
AB192 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 5 : 2008
Objective: To prospectively evaluate the frequency of upper gastrointestinal symptoms and associated disorders in morbidly obese patients with endoscopy and histology prior to their gastric bypass surgery in comparison to age and sex matched control non-obese subjects. Methods: All patients who were scheduled to undergo laparoscopic gastric bypass for treatment of morbid obesity (BMIO40) during one year period (n Z 101) were included in the study. Age and sex matched non-obese patients who were seen in the medical clinics during the study period were enrolled as control subjects. The demographic data, total body weight, body mass index, gastrointestinal symptoms were recorded and the results of upper endoscopy and histology were tabulated. Endoscopic documentation of hiatal hernia, esophagitis, gastritis, gastric polyps and peptic ulcer disease was also noted along with the histologic findings of the mucosal biopsies from the upper gastrointestinal tract. Results: The prevalence of heartburn as a symptom was significantly higher (P ! 0.05) in the morbidly obese patients (32.6%) as compared to the control group (18.8%). Endoscopically, the prevalence of hiatal hernia was also significantly higher (P ! 0.05) in the morbidly obese group (38.6%) as compared to the control group (13.8%). Similarly the frequency of endoscopically and histologically identified gastritis was significantly higher (P ! 0.01) in the morbidly obese patient group. However, the frequency of histologically identified H. pylori was not statistically different in the two groups. Conclusion: These observations suggest a significant increase in the frequency of heartburn, hiatal hernia, and histologically identified gastritis in morbidly obese patients. Table 1. Comparison of upper GI symptoms among the study and control group.
Symptoms
Study Group N Z 101 (%)
Heartburn 33 Regurgitation 19 Dysphagia 3 Upper abdominal discomfort 19 Bloating and Belching 27 Nausea 14 Duodenitis 4 )p ! 0.05 statistically significant.
(32.6) (18.8) (2.9) (18.8) (26.7) (13.8) (3.9)
Control Group N Z 101 (%) 19 12 3 16 17 12 5
(18.8) (11.8) (2.9) (15.8) (16.8) (11.8) (4.9)
Statistical significance (p value) ) 0.02 0.16 1.0 0.5 0.06 0.67 p Z 0.72
Table 2. Observed findings during upper Endoscopy.
Observed Findings
Study group N Z 101 (%)
Control Group N Z 101 (%)
Hiatal hernia Esophagitis Gastritis Acute on chronic Gastritis-Chronic Gastric polyps PUD Duodenitis
39 9 9 15 5 3 4
14 (13.8) 7 (6.9) 12 (11.8)
(38.6) (8.9) (8.9) (14.8) (4.9) (2.9) (3.9)
2 (1.9) 4 (3.9) 5 (4.9)
Statistical significance (p value) ) p ! 0.001 0.59 ) 0.02 0.24 0.69 0.72
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