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Laparascopic myotomy may offer improved outcome in younger patients compared to pneumatic dilation (PD)
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Total 24-h Daytime Nighttime
Abstracts
AJG – Vol. 95, No. 9, 2000
O 20 day 28
O 20/R 75 day 7
O 20/R 75 day 28
P value
47.3% ⫾ 5.7% 57.3% ⫾ 7.1% 33.5% ⫾ 5.7%
61.7% ⫾ 7.0% 62.4% ⫾ 6.8% 60.6% ⫾ 8.4%
52.7% ⫾ 8.0% 53.4% ⫾ 8.1% 51.8% ⫾ 8.4%
p ⬎ 0.05 p ⬎ 0.05 p ⫽ 0.035
Summary: Adding ranitidine 75mg qhs to omeprazole 20mg qAM almost doubles the percent time of intragastric pH ⬎4 during nighttime but has no influence on the daytime and overall percent time of intragastric pH ⬎4. Tolerance to ranitidine did not occur by 28 days. Conclusion: These data suggest that addition of an H2-blocker at bedtime to once daily PPI may be useful for better nocturnal acid control.
Methods: Achalasia patients undergoing PD with Rigiflex balloons from 1992–1998 and those treated with laparoscopic myotomy from 1995–1999 were evaluated. Two PD patient groups were included: 1) patients with no prior achalasia treatment in whom the 3.0 cm Rigiflex balloon was the first balloon used (Group 1) and 2) those treated with different balloon sizes (3.0, 3.5, and 4.0 cm) (Group 2). All surgically treated patients had laparoscopic Heller myotomy (Group 3) by one experienced thoracic surgeon. Patients were divided into two sub-groups; age ⬍ 40 yrs and ⱖ 40 yrs. The primary study outcome was symptom relapse within first 12 months of tx.
94 Clinical findings and risk factors for candida esophagitis: A casecontrol study JA Underwood, MD, EJ Castillo, MD, JG Hentz, MS, RF Keate, MD. Division of Gastroenterology and Hepatology, and Section of Biostatistics, Mayo Clinic Scottsdale, Scottsdale, Arizona. Purpose: Candida esophagitis (CE) is well known to occur in immunocompromised hosts. When it is has been described in immunocompetent patients, predisposing medical conditions have often been identified. Our previous study (Am J Gastroenterol 1998:93:1628) retrospectively identified potential risk factors: the purpose of this study was to determine whether these risk factors were significantly associated with CE and to determine the magnitude of each risk factor. Methods: CE was defined by the presence of fungal mycelia on brush cytology. Fifty-two patients were identified from a report of esophageal brushings submitted for cytologic evaluation between July 1996 and December 1999; five additional patients with a previous positive brushing were added. A random sample of 114 control patients was generated from a list of all patients who underwent upper endoscopy with or without brushings and/or biopsy (CPT 43235, 43239) during the 3.5 year period. Both univariate and adjusted odds ratios were measured. Results: Each potential risk factor, except diabetes mellitus, was more common in the CE group. Statistically significant differences were noted in the use of acid suppressive therapy {70% CE vs. 54% control; p 0.048, odds ratio (OR) 2.04}, antibiotic use (30% vs. 10%; p 0.002, OR 3.98), underlying malignancy (26% vs 9%; p 0.005, OR 3.71), dysmotility (28% vs. 3%; p 0.000, OR 14.44), immunosuppression (40% vs. 16%; p 0.001, OR 3.61), prior esophageal or gastric surgery (28% vs. 1%; p 0.000, OR 44.10) and inhaled corticosteroids (16% vs. 10%; p 0.312, OR 1.76). No statistically significant differences were noted between the use of oral steroids, underlying connective tissue disease, diabetes mellitus, or the presence of a barrier injury. Conclusions: The strongest risk factors for CE in our study were esophageal or gastric surgery and dysmotility. Acid suppressive therapy, antibiotics, inhaled corticosteroids, malignancy and immunosuppression were moderately strong risk factors. Diabetes mellitus and barrier injuries were not strongly associated with CE. A larger sample size is needed to assess oral steroids and connective tissue disease. Low doses of oral corticosteroids, good control of diabetes mellitus, and the way we defined barrier injury, may have influenced the assessment of these factors. 95 Laparascopic myotomy may offer improved outcome in younger patients compared to pneumatic dilation (PD) Yaezi MF, Achkar E, Rice TW, Richter JE. Departments of Gastroenterology and Thoracic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio. Prior studies using older PD balloons suggest that achalasia patients ⬎ 40 yrs of age have more favorable outcome than those ⬍ 40 yrs. However, there are no studies comparing age response of laparoscopic surgery to PD.
Results: Group 1: 57 patients (30M/27F); Group 2: 48 patients (25M/23F); and Group 3: 47 patients (21M/26F). In those ⬍ 40 yrs, only 2/18 (11%) Group 1 patients still in symptomatic remission at one yr compared to 11/17 (65%) Group 2 and 11/14 (79%) Group 3 (p ⬍ 0.001). There was a higher symptomatic remission rate at one year for laparoscopically treated patients (Group 3) ⬍ 40 yrs of age (79%) compared to PD treated patients (Group 2) (65%), however, this did not reach statistical significance (p ⫽ 0.4). No significant difference (p ⫽ 0.8) among three groups in those ⬎ 40 yrs of age. Conclusions: 1) Patients younger than 40 yrs do not respond well to PD with 3.0 cm Rigiflex balloon. 2) In this group, initial therapy with either larger PD balloon sizes or laparoscopic myotomy improves outcome. 3) Surgical myotomy may be superior to PD in patients younger than 40 yrs; however, long-term clinical studies comparing the two modalities are needed.
96 Does baseline Hp status impact erosive esophagitis (EE) healing rates? N Vakil, MD. Univ. of Wisconsin Med. School, Milwaukee, WI. P Kahrilas, MD. Northwestern U, Chicago, IL. D Magner, MSHyg, W Skammer, BSN, J Levine, MD. AstraZeneca LA, Wayne, PA. Purpose: To examine the effect of Hp status at baseline of EE healing trials on healing rates after therapy with esomeprazole (NEXIUM™), the Sisomer of omeprazole, or with omeprazole. Methods: This pooled analysis includes data from 6708 EE patients (LA Classification grades A–D) who participated in 4 similarly designed US, double-blind, randomized, controlled studies. Due to evidence that Hp status may alter response to therapy, those who tested Hp⫹ during serological screening were excluded to eliminate a potentially confounding variable in assessing the efficacy of study medications. Those later found to be Hp⫹ (from histology testing) were allowed to remain in the study. Patients were treated with once-daily esomeprazole 40 mg (E40), 20 mg (E20), or omeprazole 20 mg (O20), the standard EE healing dose, for up to 8 weeks. Treatment comparison was made using log-rank test, controlling for the biopsy Hp status at baseline. Results: See table.
Total 24-h Daytime Nighttime
Abstracts
AJG – Vol. 95, No. 9, 2000
O 20 day 28
O 20/R 75 day 7
O 20/R 75 day 28
P value
47.3% ⫾ 5.7% 57.3% ⫾ 7.1% 33.5% ⫾ 5.7%
61.7% ⫾ 7.0% 62.4% ⫾ 6.8% 60.6% ⫾ 8.4%
52.7% ⫾ 8.0% 53.4% ⫾ 8.1% 51.8% ⫾ 8.4%
p ⬎ 0.05 p ⬎ 0.05 p ⫽ 0.035
Summary: Adding ranitidine 75mg qhs to omeprazole 20mg qAM almost doubles the percent time of intragastric pH ⬎4 during nighttime but has no influence on the daytime and overall percent time of intragastric pH ⬎4. Tolerance to ranitidine did not occur by 28 days. Conclusion: These data suggest that addition of an H2-blocker at bedtime to once daily PPI may be useful for better nocturnal acid control.
Methods: Achalasia patients undergoing PD with Rigiflex balloons from 1992–1998 and those treated with laparoscopic myotomy from 1995–1999 were evaluated. Two PD patient groups were included: 1) patients with no prior achalasia treatment in whom the 3.0 cm Rigiflex balloon was the first balloon used (Group 1) and 2) those treated with different balloon sizes (3.0, 3.5, and 4.0 cm) (Group 2). All surgically treated patients had laparoscopic Heller myotomy (Group 3) by one experienced thoracic surgeon. Patients were divided into two sub-groups; age ⬍ 40 yrs and ⱖ 40 yrs. The primary study outcome was symptom relapse within first 12 months of tx.
94 Clinical findings and risk factors for candida esophagitis: A casecontrol study JA Underwood, MD, EJ Castillo, MD, JG Hentz, MS, RF Keate, MD. Division of Gastroenterology and Hepatology, and Section of Biostatistics, Mayo Clinic Scottsdale, Scottsdale, Arizona. Purpose: Candida esophagitis (CE) is well known to occur in immunocompromised hosts. When it is has been described in immunocompetent patients, predisposing medical conditions have often been identified. Our previous study (Am J Gastroenterol 1998:93:1628) retrospectively identified potential risk factors: the purpose of this study was to determine whether these risk factors were significantly associated with CE and to determine the magnitude of each risk factor. Methods: CE was defined by the presence of fungal mycelia on brush cytology. Fifty-two patients were identified from a report of esophageal brushings submitted for cytologic evaluation between July 1996 and December 1999; five additional patients with a previous positive brushing were added. A random sample of 114 control patients was generated from a list of all patients who underwent upper endoscopy with or without brushings and/or biopsy (CPT 43235, 43239) during the 3.5 year period. Both univariate and adjusted odds ratios were measured. Results: Each potential risk factor, except diabetes mellitus, was more common in the CE group. Statistically significant differences were noted in the use of acid suppressive therapy {70% CE vs. 54% control; p 0.048, odds ratio (OR) 2.04}, antibiotic use (30% vs. 10%; p 0.002, OR 3.98), underlying malignancy (26% vs 9%; p 0.005, OR 3.71), dysmotility (28% vs. 3%; p 0.000, OR 14.44), immunosuppression (40% vs. 16%; p 0.001, OR 3.61), prior esophageal or gastric surgery (28% vs. 1%; p 0.000, OR 44.10) and inhaled corticosteroids (16% vs. 10%; p 0.312, OR 1.76). No statistically significant differences were noted between the use of oral steroids, underlying connective tissue disease, diabetes mellitus, or the presence of a barrier injury. Conclusions: The strongest risk factors for CE in our study were esophageal or gastric surgery and dysmotility. Acid suppressive therapy, antibiotics, inhaled corticosteroids, malignancy and immunosuppression were moderately strong risk factors. Diabetes mellitus and barrier injuries were not strongly associated with CE. A larger sample size is needed to assess oral steroids and connective tissue disease. Low doses of oral corticosteroids, good control of diabetes mellitus, and the way we defined barrier injury, may have influenced the assessment of these factors. 95 Laparascopic myotomy may offer improved outcome in younger patients compared to pneumatic dilation (PD) Yaezi MF, Achkar E, Rice TW, Richter JE. Departments of Gastroenterology and Thoracic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio. Prior studies using older PD balloons suggest that achalasia patients ⬎ 40 yrs of age have more favorable outcome than those ⬍ 40 yrs. However, there are no studies comparing age response of laparoscopic surgery to PD.
Results: Group 1: 57 patients (30M/27F); Group 2: 48 patients (25M/23F); and Group 3: 47 patients (21M/26F). In those ⬍ 40 yrs, only 2/18 (11%) Group 1 patients still in symptomatic remission at one yr compared to 11/17 (65%) Group 2 and 11/14 (79%) Group 3 (p ⬍ 0.001). There was a higher symptomatic remission rate at one year for laparoscopically treated patients (Group 3) ⬍ 40 yrs of age (79%) compared to PD treated patients (Group 2) (65%), however, this did not reach statistical significance (p ⫽ 0.4). No significant difference (p ⫽ 0.8) among three groups in those ⬎ 40 yrs of age. Conclusions: 1) Patients younger than 40 yrs do not respond well to PD with 3.0 cm Rigiflex balloon. 2) In this group, initial therapy with either larger PD balloon sizes or laparoscopic myotomy improves outcome. 3) Surgical myotomy may be superior to PD in patients younger than 40 yrs; however, long-term clinical studies comparing the two modalities are needed.
96 Does baseline Hp status impact erosive esophagitis (EE) healing rates? N Vakil, MD. Univ. of Wisconsin Med. School, Milwaukee, WI. P Kahrilas, MD. Northwestern U, Chicago, IL. D Magner, MSHyg, W Skammer, BSN, J Levine, MD. AstraZeneca LA, Wayne, PA. Purpose: To examine the effect of Hp status at baseline of EE healing trials on healing rates after therapy with esomeprazole (NEXIUM™), the Sisomer of omeprazole, or with omeprazole. Methods: This pooled analysis includes data from 6708 EE patients (LA Classification grades A–D) who participated in 4 similarly designed US, double-blind, randomized, controlled studies. Due to evidence that Hp status may alter response to therapy, those who tested Hp⫹ during serological screening were excluded to eliminate a potentially confounding variable in assessing the efficacy of study medications. Those later found to be Hp⫹ (from histology testing) were allowed to remain in the study. Patients were treated with once-daily esomeprazole 40 mg (E40), 20 mg (E20), or omeprazole 20 mg (O20), the standard EE healing dose, for up to 8 weeks. Treatment comparison was made using log-rank test, controlling for the biopsy Hp status at baseline. Results: See table.