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Mo1171 Endoscopic Ultrasound Evaluation After Endoscopic Eradication of Esophageal Varices With Band Ligation: Does It Predict Variceal Recurrence?
Abstracts
removed by gastroscopy. No pancreatitis occurred after removal. Conclusion: In this study, endoscopist-controlled guidewire cannulation over this new PS allowed to gain the CBD in the majority of occasions. Failures occurred in intradiverticular papillae, despite PS insertion. Prevention from postERCP pancreatitis was also shown. Further studies are needed to elucidate the best algorithm after unintentional pancreatic GW cannulation in order to gain the CBD. The inner radiopaque marker of this PS was very useful to know its position.
Figure 1. Left). Common Bile Duct cannulation over a pancreatic stent. This external marker is only for endoscopic control, it is not radiopaque. Right). The inner radiopaque marker is visible in the Main Pancreatic Duct. Common Bile Duct cannulation had been achieved over the pancreatic stent.
Mo1171 Endoscopic Ultrasound Evaluation After Endoscopic Eradication of Esophageal Varices With Band Ligation: Does It Predict Variceal Recurrence? Fred O. Carneiro*, Felipe A. Retes, Sergio E. Matuguma, Debora V. Albers, Dalton M. Chaves, Marcos E. Santos, Paulo Herman, Eleazar Chaib, Paulo Sakai, Luiz C. D. albuquerque, Fauze Maluf-Filho Unit of Gastrointestinal Endoscopy of the Department of Gastroenterology of University of São Paulo and LIM-37, Sao Paulo, Brazil Background and Aims: Variceal recurrence after endoscopic band ligation for secondary prophylaxis is a frequent event. Some studies have reported a correlation between variceal recurrence and variceal re-bleeding with the endoscopic ultrasound (EUS) features of para-esophageal vessels. A prospective observational study was conducted to correlate EUS evaluation of para-esophageal varices, azygos vein and thoracic duct with variceal recurrence after endoscopic band ligation variceal eradication in patients with cirrhosis. Methods: EUS was performed before and 1 month after endoscopic band ligation variceal eradication. Para-esophageal varices, azygos vein and thoracic duct maximum diameters were evaluated in pre-determined anatomic stations. After endoscopic band ligation variceal eradication, patients were submitted to endoscopic examinations every 3 months for 1 year. We looked for EUS features that could predict variceal recurrence. Results: A total of 30 patients completed 1-year endoscopic follow-up. Seventeen (57%) patients presented variceal recurrence. There was no correlation between azygos vein and thoracic duct diameter with variceal recurrence. Larger para-esophageal varices predicted variceal recurrence in both evaluation periods (Table 1). Para-esophageal varices diameters that best correlated with variceal recurrence were 6.3 mm before endoscopic band ligation (52.9% sensitivity, 92.3% specificity, and 0.749 area under ROC curve); and 4 mm after EBL (70.6% sensitivity, 84.6% specificity, and 0.801 area under ROC curve) (Figure 1). Conclusion: We conclude that para-esophageal varices diameter measured by EUS predicts variceal recurrence within one year after endoscopic band ligation variceal eradication. Para-esophageal diameter after variceal eradication is a better recurrence predictor, because it has lower cut-off parameter, higher sensitivity and higher area under a ROC curve. Table 1. Correlation between median echoendoscopic patterns (mm)
Mo1172 Endoscopic Ultrasound (EUS) In Pseudoachalasia Workup, Is It Still Relevant? Christopher T. Chia*1,2, Sabina DeMartino1, Ikram Nasr1, Ioannis Koumoutsos1, John Meenan1 1 Gastroenterology, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom; 2Gastroenterology & Hepatology, Tan Tock Seng Hospital, Novena, Singapore Background/Aim: Pseudoachalasia is an infrequent secondary form of achalasia which can result from malignant or benign tumors, postoperative complications or paraneoplastic syndromes. Management can be vastly different between achalasia and pseudoachalasia, making it important to exclude the latter condition. Esophagogastro-duodenoscopy (EGD), high resolution manometry (HRM), barium esophagram, CT scan and EUS play complementary roles to procure a diagnosis of achalasia and exclude pseudoachalasia. This is one of the few studies that aims to evaluate the role of EUS in excluding pseudoachalasia for patients referred for achalasia workup. Methods: Data was collected retrospectively from hospital electronic records from 2008 to 2015. Our study group comprised 77 patients (femaleZ44, maleZ33) with a mean age of 62 years. All cases had a prior EGD and EUS performed. Only cases with a non-diagnostic EGD (including negative esophageal biopsies) were included. Cases with obvious mass seen on EGD were excluded. Work up included the following:(A)classic achalasia symptoms, (B)normal EGD, (C)positive HRM +/-barium for achalasia/gastro-esophageal junction outflow obstruction (GEJ-OO) and (D)had CT scan performed. Yield of excluding pseudoachalasia with addition of EUS was analysed in 4 groups: (1)A+B, (2)A+B+C, (3)A+B+D and (4)A+B+C+D. Cases referred without information on manometry, barium or CT findings were excluded appropriately in the subgroup analysis. Surveillance was performed within 6-12 months to detect any missed cases of pseudoachalasia. Statistical analysis was performed using SPSS V20 using the McNemar Chi-Square and Cochran’s Q. Results: Almost all patients (98.7%) had dysphagia as one of the main symptoms. EGD was non-diagnostic in all cases. EUS was performed in all patients. Number of pseudoachalasia cases detected in Group (1)[nZ77], Group (2)[nZ53], Group (3) [nZ38] and Group (4)[nZ26] were 0, 0, 3 and 0 respectively. With addition of EUS (Table 1), incremental detection of pseudoachalasia in these respective cohorts were 7.8% (pZ0.031), 1.9% (pZNS), 0% (pZNS) and 0% (pZNS). EUS showed a sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 85.7%, 100%, 100% and 98.6%. There was only 1 case of pseudoachalasia that was not picked up which manifested 2 years later. Other modalities (B, C and D) complemented each other to give excellent values of sensitivity, specificity and NPV (Table 2). Conclusion: In excluding pseudoachalasia, additon of EUS to a well complemented workup (typical symptoms, EGD, HRM and/or CT scan) may not yield statistically significant benefit. However, EUS demonstrated good sensitivity and excellent specificity, PPV and NPV for pseudoachalasia detection clinically and should be considered on a case-by-case basis especially in any diagnostic dilemma.
and variceal recurrence Before variceal eradication Para-esophageal varices Azygos vein Thoracic duct After variceal eradication Para-esophageal varices Azygos vein Thoracic duct
Non-recurrent
Recurrent
p value
3 8 2.4
6.3 8.9 3.1
0.017 0.391 0.515
2.4 7.8 2.7
7 8.2 2.5
0.004 0.645 0.521
AB456 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
www.giejournal.org
removed by gastroscopy. No pancreatitis occurred after removal. Conclusion: In this study, endoscopist-controlled guidewire cannulation over this new PS allowed to gain the CBD in the majority of occasions. Failures occurred in intradiverticular papillae, despite PS insertion. Prevention from postERCP pancreatitis was also shown. Further studies are needed to elucidate the best algorithm after unintentional pancreatic GW cannulation in order to gain the CBD. The inner radiopaque marker of this PS was very useful to know its position.
Figure 1. Left). Common Bile Duct cannulation over a pancreatic stent. This external marker is only for endoscopic control, it is not radiopaque. Right). The inner radiopaque marker is visible in the Main Pancreatic Duct. Common Bile Duct cannulation had been achieved over the pancreatic stent.
Mo1171 Endoscopic Ultrasound Evaluation After Endoscopic Eradication of Esophageal Varices With Band Ligation: Does It Predict Variceal Recurrence? Fred O. Carneiro*, Felipe A. Retes, Sergio E. Matuguma, Debora V. Albers, Dalton M. Chaves, Marcos E. Santos, Paulo Herman, Eleazar Chaib, Paulo Sakai, Luiz C. D. albuquerque, Fauze Maluf-Filho Unit of Gastrointestinal Endoscopy of the Department of Gastroenterology of University of São Paulo and LIM-37, Sao Paulo, Brazil Background and Aims: Variceal recurrence after endoscopic band ligation for secondary prophylaxis is a frequent event. Some studies have reported a correlation between variceal recurrence and variceal re-bleeding with the endoscopic ultrasound (EUS) features of para-esophageal vessels. A prospective observational study was conducted to correlate EUS evaluation of para-esophageal varices, azygos vein and thoracic duct with variceal recurrence after endoscopic band ligation variceal eradication in patients with cirrhosis. Methods: EUS was performed before and 1 month after endoscopic band ligation variceal eradication. Para-esophageal varices, azygos vein and thoracic duct maximum diameters were evaluated in pre-determined anatomic stations. After endoscopic band ligation variceal eradication, patients were submitted to endoscopic examinations every 3 months for 1 year. We looked for EUS features that could predict variceal recurrence. Results: A total of 30 patients completed 1-year endoscopic follow-up. Seventeen (57%) patients presented variceal recurrence. There was no correlation between azygos vein and thoracic duct diameter with variceal recurrence. Larger para-esophageal varices predicted variceal recurrence in both evaluation periods (Table 1). Para-esophageal varices diameters that best correlated with variceal recurrence were 6.3 mm before endoscopic band ligation (52.9% sensitivity, 92.3% specificity, and 0.749 area under ROC curve); and 4 mm after EBL (70.6% sensitivity, 84.6% specificity, and 0.801 area under ROC curve) (Figure 1). Conclusion: We conclude that para-esophageal varices diameter measured by EUS predicts variceal recurrence within one year after endoscopic band ligation variceal eradication. Para-esophageal diameter after variceal eradication is a better recurrence predictor, because it has lower cut-off parameter, higher sensitivity and higher area under a ROC curve. Table 1. Correlation between median echoendoscopic patterns (mm)
Mo1172 Endoscopic Ultrasound (EUS) In Pseudoachalasia Workup, Is It Still Relevant? Christopher T. Chia*1,2, Sabina DeMartino1, Ikram Nasr1, Ioannis Koumoutsos1, John Meenan1 1 Gastroenterology, Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom; 2Gastroenterology & Hepatology, Tan Tock Seng Hospital, Novena, Singapore Background/Aim: Pseudoachalasia is an infrequent secondary form of achalasia which can result from malignant or benign tumors, postoperative complications or paraneoplastic syndromes. Management can be vastly different between achalasia and pseudoachalasia, making it important to exclude the latter condition. Esophagogastro-duodenoscopy (EGD), high resolution manometry (HRM), barium esophagram, CT scan and EUS play complementary roles to procure a diagnosis of achalasia and exclude pseudoachalasia. This is one of the few studies that aims to evaluate the role of EUS in excluding pseudoachalasia for patients referred for achalasia workup. Methods: Data was collected retrospectively from hospital electronic records from 2008 to 2015. Our study group comprised 77 patients (femaleZ44, maleZ33) with a mean age of 62 years. All cases had a prior EGD and EUS performed. Only cases with a non-diagnostic EGD (including negative esophageal biopsies) were included. Cases with obvious mass seen on EGD were excluded. Work up included the following:(A)classic achalasia symptoms, (B)normal EGD, (C)positive HRM +/-barium for achalasia/gastro-esophageal junction outflow obstruction (GEJ-OO) and (D)had CT scan performed. Yield of excluding pseudoachalasia with addition of EUS was analysed in 4 groups: (1)A+B, (2)A+B+C, (3)A+B+D and (4)A+B+C+D. Cases referred without information on manometry, barium or CT findings were excluded appropriately in the subgroup analysis. Surveillance was performed within 6-12 months to detect any missed cases of pseudoachalasia. Statistical analysis was performed using SPSS V20 using the McNemar Chi-Square and Cochran’s Q. Results: Almost all patients (98.7%) had dysphagia as one of the main symptoms. EGD was non-diagnostic in all cases. EUS was performed in all patients. Number of pseudoachalasia cases detected in Group (1)[nZ77], Group (2)[nZ53], Group (3) [nZ38] and Group (4)[nZ26] were 0, 0, 3 and 0 respectively. With addition of EUS (Table 1), incremental detection of pseudoachalasia in these respective cohorts were 7.8% (pZ0.031), 1.9% (pZNS), 0% (pZNS) and 0% (pZNS). EUS showed a sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of 85.7%, 100%, 100% and 98.6%. There was only 1 case of pseudoachalasia that was not picked up which manifested 2 years later. Other modalities (B, C and D) complemented each other to give excellent values of sensitivity, specificity and NPV (Table 2). Conclusion: In excluding pseudoachalasia, additon of EUS to a well complemented workup (typical symptoms, EGD, HRM and/or CT scan) may not yield statistically significant benefit. However, EUS demonstrated good sensitivity and excellent specificity, PPV and NPV for pseudoachalasia detection clinically and should be considered on a case-by-case basis especially in any diagnostic dilemma.
and variceal recurrence Before variceal eradication Para-esophageal varices Azygos vein Thoracic duct After variceal eradication Para-esophageal varices Azygos vein Thoracic duct
Non-recurrent
Recurrent
p value
3 8 2.4
6.3 8.9 3.1
0.017 0.391 0.515
2.4 7.8 2.7
7 8.2 2.5
0.004 0.645 0.521
AB456 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
www.giejournal.org