Ligation versus ligation plus sclerotherapy for treatment of esophageal varices

"4149 INACCURATE EUS STAGING OF O E S O P H A G E A L CANCER: ASSESSMENT OF CAUSALITY Ian Dr Arnott, Emily F. Shea, Western Gen Hosp, Edinburgh United Kingdom; Klaus Zarins, John Plevris, Royal Infirmary of Edinburgh, Edinburgh United Kingdom; Ian D. Penman, Western Gen Hosp, Edinburgh United Kingdom Introduction: Endoscopic Ultrasound (EUS) is established as a major staging modality for oesophageal cancer. In initial studies suggested a correlation of surgical and EUS staging of about 80%. More recent studies have stated a lower correlation of about 50%. The major reasons for the discrepancy between pathological and EUS staging are not clear. We therefore aimed to assess the correlation between pathological (P) staging and EUS staging in a group of patients with oesophageal cancer. When the P stage and EUS stage differed as assessment of the cause for the difference was made. Methods: All patients with oesophageal cancer who underwent staging were assessed. The EUS staging and surgical staging was obtained independently without prior knowledge of the other. In those patients where the staging assessment differed, examination of the operation note, EUS report and full pathology report was made to determine the reason for the difference. Results: Between January 1999 and June 2000 94 EUS examinations were performed for oesophageal cancer. There were 61 males and 33 females with a median age of 69 years (ranges 38-85 years). Full data was available in 33 patients. Of these 33 patients, EUS staged the turnout as T1 in 3 patients, T2 in 10, T3 in 17 and T4 in 2. Nodal staging was NO in 8 patients and N1 in 25. Pathological staging correlated correctly with EUS in 2/3 ofT1 tumours. The other was understaged by EUS. Correct staging was seen in 4 of 10 T2 tumours. 3 others were understaged and 3 were overstaged. Correct staging was seen in 10 out of 17 T3 lesions. 3 turnouts were understaged and 4 were overstaged. Of the T4 tumours one was correctly staged by EUS and 1 was overstaged. The absence of nodal disease was correctly seen in 5/8 patients. Nodal disease was confirmed pathologically in 19/25 patients staged as N1. Of the cases that were wrongly staged the most common reasons were inability to pass stricture in 2, distant nodal disease 2 cases, reactive nodes with no malignancy 6 cases and distant metastatic disease not seen on EUS (or CT) 4 cases. Conclusions: Our accuracy for loco-regional staging of oesophageal cancer is comparable to more recently published data. There are a number of reasons why EUS may be inaccurate. These include inability to complete a full examination, nodal tissue that is non-malignant and non-visualised metastatic disease. With these potential factors in mind EUS remains an excellent tool in the multi-modality staging of oesophageal cancer. "4150 LIGATION VERSUS LIGATION PLUS SCLEROTHERAPY F O R TREATMENT OF ESOPHAGEAL VARICES. Ximena O. Morales, Ling T Vargas, Loreto A. Ovalle, Rene G. Estay, Juan Ramon H. Soto, Univ de Chile, Santiago Chile It has been claimed that endoscopic ligation (EL) is better than EL plus sclerotherapy (ES) for the treatment of patients with bleeding esophageal varices (EV). Objective. Comparing the long-term results of EL versus EL + ES for the treatment of EV. Methods. Patients with active or inactive bleeding due to VE were randomized to treatment with EL or EL + ES. Patients bleeding from gastric varices, homeless or those who refuse endoscopic treatment were excluded. The EL group was ligated weekly until eradication of EV. In the other group the size of EV was reduced ligating them for 2 - 4 sessions followed by complete eradication with 1% polydocanol. Both groups were followed until re-development of EV, recurrent hemorrhage for EV, liver transplant or death. Statistical analysis was done using the following tests: Chi square, Wilcoxon and log-rank for Kaplan Meir. Results. Between August 1996 and December 1999, 62 patients were included in the EL group and 61 in the EL + ES group. Twenty-five patients were excluded. Demographic and clinical characteristics were comparable between the groups. Mean follow up was 17.6 months (1 - 42)in the EL group and 17.2 months ( 1 - 42) in the EL + ES group. EV eradication was achieved in 53 of 56 patients who compleated treatment in the EL group versus 53 of 55 patients in the EL + ES group (NS); the number of sessions was 4.6 (2 - 8) in the EL group versus 5.5 (3 - 10) in the EL + ES ~ o u p (p = 0.0218). The probability of EV recurence at 1, 2 and 3 years was 0.03, 0.4 and 0.71 in the EL group versus 0.0, 0.17 and 0.45 in the EL + ES ,~roup, respectively (p = 0.053). No significant differences were found for recurrent bleeding (10% versus 8%), complications ( 8% versus 16%) or mortality (21% versus 23%), respectively. One patient died from massive hemorrhage at admission. No patient re-bled once EV had been eradicated. Conclusions. Eradication of EV using EL + ES implies a greater number of sessions compared to EL. In the medium term, EV recurs more frequently when treatment is done with EL exclusively, which implies a closer follow up for this group. We propose the use of EL + ES as the treatment of choice for the eradication of EV in patients with poor treatment adhesivety.

VOLUME 53, NO. 5, 2001

"4151 A NOVEL USE OF ENDOSCOPIC C LIP S IN THE TREATMENT PLANNING FOR RADIATION THERAPY (XRT) FOR ESOPHAGEAL CANCER Patrick R. Pfau, Huong Pham, Ananya Das, Gerard A. Isenherg, V Diwan, Amitabh Chak, Univ Hospitals of Cleveland, Cleveland, OH Background: Radiotherapy is an important modality in the treatment and palliation of esophageal cancer. Accurate simulation of the radiation ensures optimal therapy is provided while limiting toxicity. Presently, XRT simulation of the esophagus depends on the use of barium studies, CT scans, and endoscopy reports. Aim: To determine the feasibility and ability of endoscopic mucosal clips for localizing the proximal and distal aspects of esophageal tumors during XRT simulation. Methods: Patients with esophageal carcinoma scheduled for radiation therapy underwent EGD and endoscopic mucosal clips were placed at the proximal and distal ends of the tumor. At subsequent XRT simulation the radiation oncologist simulated the field with information based on barium study, CT scan, and endoscopy report. They then assessed the ease of identification of the margins of the tumor, the shift in the field isocenter, and change in the radiation field width and length because of the addition of clips. Results: Three patients with esophageal cancer had endoscopic clips placed followed by XRT simulation within 7 days. The margins of the tumor could be easily identified by identification of the endoscopic clips on pre-simulation radiography in all patients. One patient could not be accurately simulated by CT and barium swallow because of a large hiatal hernia and was simulated solely by the markings of the endoscopic clips. In two patients, simulation with the use of clips caused a shift in the isocenter with a mean longitudinal shift of 5.cm and a mean lateral shift of the radiation field of 2 cm. In each patient management was affected and the field of radiation was changed because of the use of endoscopic clips. Conclusion: Endoscopic mucosal clips can be easily visualized when XRT simulation is performed within 1 week of placement. As markers, they can clearly affect and improve treatment planning of radiation therapy in esophageal cancer. "4152 AUTOFLUORESCENCE SPECTROSCOPY TO D I F F E R E N T I A T E H IG H GRADE DYSPLASIA AND CANCER FROM LOW GRADE DYSPLASIA IN BARRETT'S ESOPHAGUS. Bhaskar Banerjee, Washington Univ, St. Louis, MO; Sangeeta Agarwal, Holakere R. Chandrasekhar, Univ of Missouri, Columbia, MO INTRODUCTION: The ability to distinguish high grade dysplasia (HGD) or intramucosal carcinoma (CA) from low grade dysplasia (LGD} in an otherwise unremarkable Barrett's esophagus (BE) may lead to timely surgical referral. We studied the autofluorescence spectra in 20 patients with BE with dysplasia or cancer to see ifautofluorescence spectroscopy can differentiate HGD and CA from LGD. METHODS: Tissue samples were obtained at endoscopy from HGD & CA (n = 6) and LGD (n = 14), with samples of normal squamous mucosa in each patient serving as control (n = 20). All samples were immediately snap frozen in liuid Nitrogen and stored at -70 Celsius. Before spectroscopy, samples were thawed over ice and moistended with phosphate buffered saline at pH 7.4 (PBS). A spectrofiuorometer with a Xenon lamp and excitation and emission spectrometers (Shimatzu RF 5301 PC columbia, MD) with a specially constructed sample holder was used. Emission spectra were recorded with excitation below 400 nm and emission at wavelengths 10 nm above the excitation. Autofluorescence intensity in arbitrary units (y axis) was plotted against wavelength (xaxis). All specra were digitally recorded and later compared to histology. The intensity of maximum emission in each tissue sample was normalized by dividing it by the corresponding intensity of the control sample (normal squamous) in each subject. RESULTS: The ratios of mean intensity ± SE were: 1.9 ± 0.2 (LGD); 3.75 ± 1.0 (HGD & CA). The difference between groups was significant: p = 0.02 (unpaired t test). CONCLUSIONS: Normalized autofluorescence intensity appears to ba able to differentiate high grade dysplasia and cancer from low grade dysplasia. This needs to be verified in- vivo. The use of a laser was not required. Further work needs to be done to see if this Xenon lamp based method can distinguish high grade dysplasia from intranmcosal carcinoma.

GASTROINTESTINAL ENDOSCOPY

AB153