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Inter-Observer Agreement of Milder Form of GERD - Interactive Electronic Study in a Japanese Meeting
Abstracts
S1341 Photodynamic Therapy for Early Esophageal Cancer Chan Sup Shim, Young Koog Cheon, In Seop Jung, Bong Min Ko, Joo Young Cho, Joon Seong Lee, Moon Sung Lee Background/Aim: Although photodynamic therapy (PDT) has been used for the endoscopic treatment of digestive cancer, its curative efficacy remains uncertain. The aim of this study was to evaluate the curative role of PDT in early esophageal cancer. Methods: Nine patients with histologically proven early esophageal cancer (if surgery was contraindicated for old age (O80 years), poor surgical risk; Karnofsky performance status of at least 30%; refused operation) were injected with intravenous hematoporphyrin derivative (2 mg/kg) and PDTwas performed 48 hours later. Response to treatment was assessed with gastroscopy with biopsies. Results: Mean follow-up time was 13.5 months (3.3w34.3 months). According to TNM stage of endoscopic ultrasonography, T1 was 6, T2 was 3 cases. Complete remission (CR) to initial and consecutive PDT was observed in 8 cases. One case of failure was observed (This patient refused further treatment and was lost follow-up). Among CR cases, the recurrence rate was 12.5% (1/8), and time from initial PDT to recurrence was 117 days. Conclusion: PDT using hematoporphyrin derivative as the photosensitizser represents a safe and efficient method for treatment of early cancer. However, the study which requires long-term follow up period in large population is needed for confirmation. Key Words: Photodynamic therapy, Early esophageal cancer Table 2. Characteristics of the patients and results from PDT Patient no
Sex/ Age
EUS Histology
1
M/70
T2
2 3
F/62 M/82
4 5 6 7 8 9
M/66 M/68 M/77 M/64 M/77 M/68
Follow up Remission (months) Comments
Energy (J/cm2)
Sessions of PDT
Squamous
120
1
CR
29
T1 T1
Squamous Adenocarcinoma (P/D)
200 180
2 1
PR CR
4 13
T1 T1 T1 T1 T2 T1
Squamous Squamous Squamous Squamous Squamous Squamous
200 180 180 160 200 180
2 1 2 2 2 1
CR CR CR CR CR CR
4 3 29 21.3 5 3
local recurrence RT E-G junction cancer
S1343 Comparison of Polyflex and Ultraflex Stent for Palliation of Inoperable Neoplastic Esophageal Strictures. A Single Center Prospective Study Mario De Bellis, Pietro Marone, Giovanni Battista Rossi, Giovanni Di Nardo, Anna Crispo, Marco Esposito, Rosaria Aprea, Alfonso Tempesta Background: Covered self expanding metallic stents (SEMS) offer effective palliation of esophageal strictures. An alternative to SEMS is a self-expanding, covered, plastic esophageal stent (SEPS). In previous reports, SEPS were well tolerated and had an acceptable complication rate. Moreover SEPS cost approximately 50% less than SEMS. Aim: To compare palliative effects and complication rate between one type of covered SEMS and the SEPS commercially available. Patients and Methods: From 1/03 to 05/06, 24 consecutive patients (pts) with dysphagia due to inoperable neoplastic stricture of the esophagus were enrolled in the study. There were 15 males and 9 females, with a median age of 66 years (range 45-82). The esophageal stricture was due to primary cancer in 18 pts and recurrence at the gastroesophageal anastomosis in 2. The remaining 4 pts had a stricture of the distal esophagus due to extrinsic metastatic lung cancer (2) and mediastinal NHL (2). The pts were selected to receive either covered UltraflexÒ or PolyflexÒ stent, according to the choice of the endoscopist. Dysphagia was scored on a 4 point scale, recorded before and after stent insertion and during follow-up. Technical success, early and late complications were recorded. Results: Eleven pts received a total of 14 Polyflex, since 3 pts were restented after early (1) and late (2) migrations of the stent. Ultraflex was placed in 17 cases, since 1 pts received Ultraflex immediately after the early failure of Polyflex, another pts received 2 consecutive Ultraflex after 2 consecutive Polyflex because of recurrent late migration of the stent and in 1 case Ultraflex was placed twice due to tumor overgrowth. In 9 pts, the cancer stricture extended to the cardias; of these, 5 received Polyflex and 4 Ultraflex. Mean duration of the follow up was 142 (5-450) days for the Polyflex group and 127 (27-302) days for the Ultraflex group. The two types of stenst were equally effective in palliation of dysphagia (p 0.7). However, Polyflex required dilation of the stricture in all cases (100% vs 12%; p 0.0001), was associated with a lower technical (78% vs 94%; p 0.3) and clinical (71% vs 94%; p 0.2) success and migrated more often (45% vs 0; p 0.02) than Ultraflex. The latter was more often reobstructed by tumor ingrowth (18%). There were no perforation, hematemesis or perioperative death. Conclusions: Our data confirms that SEPS is an alternative to SEMS. However, Polyflex always requires dilation of the stricture, are more difficult to be placed and have a higher migration rate compared to Ultraflex. Further prospective trials comparing Polyflex stents with SEMS are needed.
S1344 Inter-Observer Agreement of Milder Form of GERD - Interactive Electronic Study in a Japanese Meeting Yoshio Hoshihara, Michio Hongo
S1342 Long Term Outcome of Self Expanding Metal Stents (SEMS) for Palliation of Dysphagia in Esophageal Malignancies Augusto Villaverde, Horacio Martinez, Nestor Landoni, Alberto Bernedo, Nestor Chopita Aim: to evaluate if self-expanding metal stents improve the dysphagia and general status in patients with esophageal carcinoma. Patients and Methods: From June 1995 to November 2006, 153 SEMS were placed in 151 patients, (118 m. and 33 f., mean age 66.3 years), for palliation of malignant dysphagia in a prospective study in our service. The criteria for evaluation were: clinical (dysphagia score, and karnofsky score), X-ray and endoscopy. Late complications were considered when they occurred after thirty days after the placement of the stent. Results: one hundred and twenty patients (79.47%) were finally included for follow-up. The late complication rate was 23/120 (19.16%), 7 migrations; 5 tumour overgrowth; 1 ulceration; 6 severe chest pain; 1 granulation tissue ingrowth; 3 esophagopleural fistula. Twenty two (95.65%) complications were clinically and endoscopically treated. One case was sent to surgery. The median survival was 5.9 months (range 1 to 16 m). The dysphagia score improved in two points in 36% of the patients and in one point in 32.4% of the patients and the karnofsky score increased in ten points in 34.5% over the baseline. Conclusions: we believe that self expanding metal stents are a good option for patients with unresectable esophageal carcinoma and improve the dysphagia and general status). The late complication rate is similar to the plastic ones according data published.
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Background: Diagnostic value of minimal change is controversial because of the inconsistency of inter-observer variation. However, grading of minimal change esophagitis, Grade M, defined as white blurring and/or erythema is widely used in Japan. Aim: To find the consistency of inter-observer agreement on such changes, and to establish, if possible, a new diagnostic criteria for endoscopic minimal change esophagitis. Method: Interactive survey on the endoscopic diagnosis for very milder form of esophagitis were conducted at the meeting of Japan GERD Society, with active attendant (who responded to electronic survey) of 506 doctors. Sixty-five% of them were gastroenterologists with experience of endoscopy more than 5 year. Ten% of them were surgeon with more than 5 years experience of endoscopy. Sixteen% of them did not disclose their specialty or experiences. Endoscopic still images of normal to Grade B esophagitis from 8 patients were shown in random order on a large screen. One to 3 images per patient were shown to the attendants. First series of presentation did not inform the attendants where to focus, and the latter series of presentation inform them the lesion to focus. Kappa values were calculated from the electronic answer. After the presentation of 2 cases, instruction was given to divide grade M to grade MW (white blurring) and grade MR (erythema: redness). Result: Kappa value using a M grading was 0.0298, which increased to 0.2708 when the new grading of MW and MR were instructed. Kappa value for the first presentation in entire series of patients was 0.2708, which increased to 0.3468 after informing the lesion to focus. Agreement ratio increased when the point of focus was instructed. However, discrimination from normal to MW, MW to MR, MR to A and A to B were not well documented from the survey. Experience duration of endoscopy seemed to contributed the agreement in general. Highest Kappa value was obtained in experienced gastroenterolgists when seeing the images with focus to evaluate. Conclusion: Newly defined grading of Grade MW and MR increased the diagnostic accuracy of milder form of esophagitis. However, discrimination of milder form of esophagitis is still difficult because of the existence of various kinds of lesions identified in the milder form of esophagitis. Instructive description for such grading may improve diagnostic accuracy.
Volume 65, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY AB149
S1341 Photodynamic Therapy for Early Esophageal Cancer Chan Sup Shim, Young Koog Cheon, In Seop Jung, Bong Min Ko, Joo Young Cho, Joon Seong Lee, Moon Sung Lee Background/Aim: Although photodynamic therapy (PDT) has been used for the endoscopic treatment of digestive cancer, its curative efficacy remains uncertain. The aim of this study was to evaluate the curative role of PDT in early esophageal cancer. Methods: Nine patients with histologically proven early esophageal cancer (if surgery was contraindicated for old age (O80 years), poor surgical risk; Karnofsky performance status of at least 30%; refused operation) were injected with intravenous hematoporphyrin derivative (2 mg/kg) and PDTwas performed 48 hours later. Response to treatment was assessed with gastroscopy with biopsies. Results: Mean follow-up time was 13.5 months (3.3w34.3 months). According to TNM stage of endoscopic ultrasonography, T1 was 6, T2 was 3 cases. Complete remission (CR) to initial and consecutive PDT was observed in 8 cases. One case of failure was observed (This patient refused further treatment and was lost follow-up). Among CR cases, the recurrence rate was 12.5% (1/8), and time from initial PDT to recurrence was 117 days. Conclusion: PDT using hematoporphyrin derivative as the photosensitizser represents a safe and efficient method for treatment of early cancer. However, the study which requires long-term follow up period in large population is needed for confirmation. Key Words: Photodynamic therapy, Early esophageal cancer Table 2. Characteristics of the patients and results from PDT Patient no
Sex/ Age
EUS Histology
1
M/70
T2
2 3
F/62 M/82
4 5 6 7 8 9
M/66 M/68 M/77 M/64 M/77 M/68
Follow up Remission (months) Comments
Energy (J/cm2)
Sessions of PDT
Squamous
120
1
CR
29
T1 T1
Squamous Adenocarcinoma (P/D)
200 180
2 1
PR CR
4 13
T1 T1 T1 T1 T2 T1
Squamous Squamous Squamous Squamous Squamous Squamous
200 180 180 160 200 180
2 1 2 2 2 1
CR CR CR CR CR CR
4 3 29 21.3 5 3
local recurrence RT E-G junction cancer
S1343 Comparison of Polyflex and Ultraflex Stent for Palliation of Inoperable Neoplastic Esophageal Strictures. A Single Center Prospective Study Mario De Bellis, Pietro Marone, Giovanni Battista Rossi, Giovanni Di Nardo, Anna Crispo, Marco Esposito, Rosaria Aprea, Alfonso Tempesta Background: Covered self expanding metallic stents (SEMS) offer effective palliation of esophageal strictures. An alternative to SEMS is a self-expanding, covered, plastic esophageal stent (SEPS). In previous reports, SEPS were well tolerated and had an acceptable complication rate. Moreover SEPS cost approximately 50% less than SEMS. Aim: To compare palliative effects and complication rate between one type of covered SEMS and the SEPS commercially available. Patients and Methods: From 1/03 to 05/06, 24 consecutive patients (pts) with dysphagia due to inoperable neoplastic stricture of the esophagus were enrolled in the study. There were 15 males and 9 females, with a median age of 66 years (range 45-82). The esophageal stricture was due to primary cancer in 18 pts and recurrence at the gastroesophageal anastomosis in 2. The remaining 4 pts had a stricture of the distal esophagus due to extrinsic metastatic lung cancer (2) and mediastinal NHL (2). The pts were selected to receive either covered UltraflexÒ or PolyflexÒ stent, according to the choice of the endoscopist. Dysphagia was scored on a 4 point scale, recorded before and after stent insertion and during follow-up. Technical success, early and late complications were recorded. Results: Eleven pts received a total of 14 Polyflex, since 3 pts were restented after early (1) and late (2) migrations of the stent. Ultraflex was placed in 17 cases, since 1 pts received Ultraflex immediately after the early failure of Polyflex, another pts received 2 consecutive Ultraflex after 2 consecutive Polyflex because of recurrent late migration of the stent and in 1 case Ultraflex was placed twice due to tumor overgrowth. In 9 pts, the cancer stricture extended to the cardias; of these, 5 received Polyflex and 4 Ultraflex. Mean duration of the follow up was 142 (5-450) days for the Polyflex group and 127 (27-302) days for the Ultraflex group. The two types of stenst were equally effective in palliation of dysphagia (p 0.7). However, Polyflex required dilation of the stricture in all cases (100% vs 12%; p 0.0001), was associated with a lower technical (78% vs 94%; p 0.3) and clinical (71% vs 94%; p 0.2) success and migrated more often (45% vs 0; p 0.02) than Ultraflex. The latter was more often reobstructed by tumor ingrowth (18%). There were no perforation, hematemesis or perioperative death. Conclusions: Our data confirms that SEPS is an alternative to SEMS. However, Polyflex always requires dilation of the stricture, are more difficult to be placed and have a higher migration rate compared to Ultraflex. Further prospective trials comparing Polyflex stents with SEMS are needed.
S1344 Inter-Observer Agreement of Milder Form of GERD - Interactive Electronic Study in a Japanese Meeting Yoshio Hoshihara, Michio Hongo
S1342 Long Term Outcome of Self Expanding Metal Stents (SEMS) for Palliation of Dysphagia in Esophageal Malignancies Augusto Villaverde, Horacio Martinez, Nestor Landoni, Alberto Bernedo, Nestor Chopita Aim: to evaluate if self-expanding metal stents improve the dysphagia and general status in patients with esophageal carcinoma. Patients and Methods: From June 1995 to November 2006, 153 SEMS were placed in 151 patients, (118 m. and 33 f., mean age 66.3 years), for palliation of malignant dysphagia in a prospective study in our service. The criteria for evaluation were: clinical (dysphagia score, and karnofsky score), X-ray and endoscopy. Late complications were considered when they occurred after thirty days after the placement of the stent. Results: one hundred and twenty patients (79.47%) were finally included for follow-up. The late complication rate was 23/120 (19.16%), 7 migrations; 5 tumour overgrowth; 1 ulceration; 6 severe chest pain; 1 granulation tissue ingrowth; 3 esophagopleural fistula. Twenty two (95.65%) complications were clinically and endoscopically treated. One case was sent to surgery. The median survival was 5.9 months (range 1 to 16 m). The dysphagia score improved in two points in 36% of the patients and in one point in 32.4% of the patients and the karnofsky score increased in ten points in 34.5% over the baseline. Conclusions: we believe that self expanding metal stents are a good option for patients with unresectable esophageal carcinoma and improve the dysphagia and general status). The late complication rate is similar to the plastic ones according data published.
www.giejournal.org
Background: Diagnostic value of minimal change is controversial because of the inconsistency of inter-observer variation. However, grading of minimal change esophagitis, Grade M, defined as white blurring and/or erythema is widely used in Japan. Aim: To find the consistency of inter-observer agreement on such changes, and to establish, if possible, a new diagnostic criteria for endoscopic minimal change esophagitis. Method: Interactive survey on the endoscopic diagnosis for very milder form of esophagitis were conducted at the meeting of Japan GERD Society, with active attendant (who responded to electronic survey) of 506 doctors. Sixty-five% of them were gastroenterologists with experience of endoscopy more than 5 year. Ten% of them were surgeon with more than 5 years experience of endoscopy. Sixteen% of them did not disclose their specialty or experiences. Endoscopic still images of normal to Grade B esophagitis from 8 patients were shown in random order on a large screen. One to 3 images per patient were shown to the attendants. First series of presentation did not inform the attendants where to focus, and the latter series of presentation inform them the lesion to focus. Kappa values were calculated from the electronic answer. After the presentation of 2 cases, instruction was given to divide grade M to grade MW (white blurring) and grade MR (erythema: redness). Result: Kappa value using a M grading was 0.0298, which increased to 0.2708 when the new grading of MW and MR were instructed. Kappa value for the first presentation in entire series of patients was 0.2708, which increased to 0.3468 after informing the lesion to focus. Agreement ratio increased when the point of focus was instructed. However, discrimination from normal to MW, MW to MR, MR to A and A to B were not well documented from the survey. Experience duration of endoscopy seemed to contributed the agreement in general. Highest Kappa value was obtained in experienced gastroenterolgists when seeing the images with focus to evaluate. Conclusion: Newly defined grading of Grade MW and MR increased the diagnostic accuracy of milder form of esophagitis. However, discrimination of milder form of esophagitis is still difficult because of the existence of various kinds of lesions identified in the milder form of esophagitis. Instructive description for such grading may improve diagnostic accuracy.
Volume 65, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY AB149