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N-butyl-2-cyanoacrylate (Histoacryl) injection therapy in the treatment of gastric variceal bleeding
"4119 WHAT IS THE ROLE OF ENDOSCOPIC ULTRASOUND (EUS) FOLLOWING CHEMOTHERAPY FOR ESOPHAGEAL cARCINOMA: ARE WE ASKING THE RIGHT QUESTIONS? John K. Meenan, Bobby P. Prasad, Endosonegraphy Ctr, St Thomas' Hosp, London United Kingdom; Anthony Antonieu, Dept Surg, Queeen Mary's Hosp, Sidcup, London United Kingdom; Giles Rottenberg, Endosonography Ctr, St Thomas' Hosp, London United Kingdom Background: EUS is superior to CT for the T/N staging of esophageal tumours, however, like all imaging modalities, its value following the use of neo-adjuvant chemotherapy is uncertain. The increasing use of chemotherapy highlights the importance of defining this role. Aim: To determine the accuracy of EUS following chemotherapy with respect to the identification of residual tumor, metastatic lymph nodes and the resectability of involved tissue. Methods: EUS was performed using Olympus GFUM20/GFUM200 echoendoscopes. The accuracy of EUS for the TfN staging of all cancers of the esophagus and gastro-esophageal junction was determined (n=175). Films of patients who had recieved neo-adjurant chemotherapy (n=29) were reviewed in a blinded fashion for presence of a mass lesion, changes in residual mass echogenicity, restoration of wall layer pattern and presence of neoplastic appearing nodes as assessed by standard criteria (size, shape, border and echogenicity). Results: One-hundred and seventy-five patients were assessed by EUS with 46 of these undergoing surgery. Accuracy of T-staging was 89% with N-staging specificity and sensitivity being 94% and 71% respectively. A further 29 cases (M:22; F:7; Age 37-81 yrs, median 65yrs) were assessed by EUS before and after chemotherapy; of these 22 underwent surgery. The specificity and sensitivity for predicting the presence of tumour was 100% and 50% respectively, based on wall thickening or full restoration of layers. The accuracy of predicting resectability (ie
"4121 N-BUTYL-2- CYANOAC RYLATE (HISTOACRYL) I N J E C T I O N THERAPY IN THE TREATMENT OF GASTRIC VARICEAL BLEEDING Kwang Hyun Ko, Kwang Jae Lee, Ki Balk Hahm, Sung Won Cho, Ajou Univ, Suwon South Korea Background and Aim: While some eases of gastric varices successfully treated with sclerothrapy have been reported, the procedure is fi'equently ineffective, and it is associated with a high incidence of early recurrennt bleeding. Recently Histoacryl has been successfully used to control the bleeding from gastric varices. In this study, we report our experience of Histoacryl injection therapy for gastric variceal bleeding. Methods; From March 1994 to September 2000, we studied the effectiveness of Histeacryl injection therapy in 61 patients with gastric variceal bleeding confirmed by endoscopically. Histoacryl diluted with lipiodol(l:l.5) was injected intravariceally. Results; The patients were composed of 47 males and 14 females and their mean age was 50.9 years. Underlying liver diseases of the patients were alcoholic liver cirrhosis in 33(54.1%), B-viral liver cirrhosis in 18(29.5%), C-viral liver cirrhosis in 2(3.3%), and other causes in 8(13.1%). The Child-Pugh classification in the patients was Child class A in 16(26.2%), B in 32(52.5%) and C in 13(21.3%). The number of patients by Forrest classification was Forrest Ia in 19(31.1%), Ib in 16(26.2%), H in 23(37.7%) and III in 3(4.9%). Mean doses of used Histoacryl were 1.90±1.45cc. Initial hemostasis rate and early rebleeding rate within 30 days and late rebleeding rate were 90.1% (55/61), 12.7% (7/55) and 32.7%(18/55), respectively. Hospital mortality is 18.2%(12/61). Causes of death included hypovolemic shock due to uncontrolled bleeding (n=5), hepatic failure (n=3) and multiorgan failure (n=4). Complications related to Histoacryl injection were Histoacryl-induced ulcer (n=l), aspiration pneumonia (n=l) and sepsis (n=2). Conclusions; Histoacryl injection in the gastric variceal bleeding is a rapid, easy, relatively safe, and effective treatment modailty to control the bleeding and prevent rebleeding, without fatal complications such as systemic embolization of Histeacryl.
"4120 ENDOSCOPIC ABLATION OF BARRETT'S ESOPHAGUS BY ARGON BEAM PLASMA COAGULATION: LONG TERM FOLLOWUP Clive D. Morris, James P. Byrne, Stephen E. Attwood, Hope Hosp, Manchester United Kingdom The incidence of esophageal adenocarcinoma has risen dramatically over the last 30ys. European patients with Barrett's esophagus have a risk of approximately 1:100 patient years for the development of this tumour. Endoscopic ablation of Barrett's esophagus has been shown to lead to the regrowth of a neo-squamous epithelium if gastro-esophageal reflux is con~rolled, but the incidence of subsequent tumour formation is unknown. Here we report the long-term follow up of 49 patients who have undergone ~mdoscopic ablation of Barrett's esophagus by argon beam plasma coagulation (ABPC). Patients: Of the 49 patients, 9 had low-grade dysplasia (LGD), .9 had high-grade dysplasia (HGD) with the remainder having non-dysplastic Barrett's metaplasia prior to ablation. The mean length of Barrett's segment was 6.7cm (range 3-16cm). 10 patients had reflux control by antireflux surgery with the remainder receiving high dose proton pump inhibitor therapy. Ablation: ABPC was applied in longitudinal strips with mucosal bridges left between strips. Remaining Barrett's metaplasia was ablated at further sessions. All metaplasia was ablated to within 3cm of the gastro-esophageal junction. All procedures were carried out as day case procedures under intravenous sedation. Follow-up: To date, 1 patient has died of unrelated disease but the remaining patients have been followed by regular endoscopic surveillance for a mean of 3ys to give a total follow up of 144.1 patient years. No malignancy has developed in any patient during lbllow-up. Conclusion: This represents the longest reported follow-up after prophylactic ablation of long-segment Barrett's esophagus. The absence of malignant complications in all patients, including those with high-grade dysplasia strengthens the argument for endoscopic ablation in the prevention of esophageal adenocarcinoma.
"4122 A MODIFIED METHOD OF BOTULINUM B O X I N INJECTION IN PATIENTS WITH ACHALASIA MIGHT BE MORE EFFECTIVE THAN STANDARD ADMINISTRATION TECHNIQUE Jan Martinek, Eva Mecova, Julius Spicak, Clin of hepatogastroenterology, IKEM, Prague Czech Republic Background & aim: Injection of botulinum toxin into the lower esophageal sphincter (LES) is an effective treatment for achalasia. However, about 60% of patients experience a relapse within 6 months which requires further treatment. We hypothesized that better LES infiltration by toxin could improve the effect. The aim of this study was to investigate the efficacy of a modified method of intrasphincteric botulinum toxin injection in patients with achalasia. Patients and method: We treated 16 patients (mean age 46.1 yrs, range 24-73) with achalasia (12 patients with classic and 4 with vigorous achalasia). We diluted 100 units of botulinum toxin with 8 ml of normal saline. Thereafter we injected aliquots of 1 ml (12.5 units per milliliter of saline) into quadrants of the LES from retrovision and then into each quadrant from direct vision. The patients completed a questionnaire where they evaluated the degree of dysphagia and regurgitation on a visual analogue scale (measured on a scale from 1= none to 5= severe) before, 1 week, 3 and 8 months after treatment. We performed esophageal manometry before and 3 months after injection. Results: All patients responded well to treatment within one week after the injection. No patient had a relapse requiring treatment during the 8 months of follow-up. At 3 months, all treated patients were asymptomatie. At 8 months, 30% of patients reported a mild-to-moderate relapse of solid dysphagia. The mean (±SD) scores before, 3 and 8 months after the treatment were: solid dysphagia: 4.8 (0.4); 1.4 (0.6) and 2.9 (0.8); fluid dysphagia: 3.9 (1.2); 1.1 (0.3) and 1.7 (1.2); regurgitation: 3.7 (1.6); 1.2 (0.4) and 1.4 (1.1), respectively (p<0.05 before vs. after for all scores). The mean (±SD) basal LES pressure decreased from 45.3 (23.6) mmHg before to 28.3 (8.3) mmHg 3 months after treatment; the mean (±SD) percentage of LES relaxation increased from 50.4% (33) before to 75.7% (21) after treatment. Conclusion: Dividing the injection of botulinum toxin into two parts - 50 units injected from retrovision and direct vision each - produced a rapid response which was sustained for 8 months in the majority of treated patients. This technique of injection might be superior to standard injection from direct vision. We suggest a randomized trial comparing these two techniques of botulinum toxin administration should be performed.
VOLUME 53, NO. 5, 2001
GASTROINTESTINAL ENDOSCOPY
AB145
"4121 N-BUTYL-2- CYANOAC RYLATE (HISTOACRYL) I N J E C T I O N THERAPY IN THE TREATMENT OF GASTRIC VARICEAL BLEEDING Kwang Hyun Ko, Kwang Jae Lee, Ki Balk Hahm, Sung Won Cho, Ajou Univ, Suwon South Korea Background and Aim: While some eases of gastric varices successfully treated with sclerothrapy have been reported, the procedure is fi'equently ineffective, and it is associated with a high incidence of early recurrennt bleeding. Recently Histoacryl has been successfully used to control the bleeding from gastric varices. In this study, we report our experience of Histoacryl injection therapy for gastric variceal bleeding. Methods; From March 1994 to September 2000, we studied the effectiveness of Histeacryl injection therapy in 61 patients with gastric variceal bleeding confirmed by endoscopically. Histoacryl diluted with lipiodol(l:l.5) was injected intravariceally. Results; The patients were composed of 47 males and 14 females and their mean age was 50.9 years. Underlying liver diseases of the patients were alcoholic liver cirrhosis in 33(54.1%), B-viral liver cirrhosis in 18(29.5%), C-viral liver cirrhosis in 2(3.3%), and other causes in 8(13.1%). The Child-Pugh classification in the patients was Child class A in 16(26.2%), B in 32(52.5%) and C in 13(21.3%). The number of patients by Forrest classification was Forrest Ia in 19(31.1%), Ib in 16(26.2%), H in 23(37.7%) and III in 3(4.9%). Mean doses of used Histoacryl were 1.90±1.45cc. Initial hemostasis rate and early rebleeding rate within 30 days and late rebleeding rate were 90.1% (55/61), 12.7% (7/55) and 32.7%(18/55), respectively. Hospital mortality is 18.2%(12/61). Causes of death included hypovolemic shock due to uncontrolled bleeding (n=5), hepatic failure (n=3) and multiorgan failure (n=4). Complications related to Histoacryl injection were Histoacryl-induced ulcer (n=l), aspiration pneumonia (n=l) and sepsis (n=2). Conclusions; Histoacryl injection in the gastric variceal bleeding is a rapid, easy, relatively safe, and effective treatment modailty to control the bleeding and prevent rebleeding, without fatal complications such as systemic embolization of Histeacryl.
"4120 ENDOSCOPIC ABLATION OF BARRETT'S ESOPHAGUS BY ARGON BEAM PLASMA COAGULATION: LONG TERM FOLLOWUP Clive D. Morris, James P. Byrne, Stephen E. Attwood, Hope Hosp, Manchester United Kingdom The incidence of esophageal adenocarcinoma has risen dramatically over the last 30ys. European patients with Barrett's esophagus have a risk of approximately 1:100 patient years for the development of this tumour. Endoscopic ablation of Barrett's esophagus has been shown to lead to the regrowth of a neo-squamous epithelium if gastro-esophageal reflux is con~rolled, but the incidence of subsequent tumour formation is unknown. Here we report the long-term follow up of 49 patients who have undergone ~mdoscopic ablation of Barrett's esophagus by argon beam plasma coagulation (ABPC). Patients: Of the 49 patients, 9 had low-grade dysplasia (LGD), .9 had high-grade dysplasia (HGD) with the remainder having non-dysplastic Barrett's metaplasia prior to ablation. The mean length of Barrett's segment was 6.7cm (range 3-16cm). 10 patients had reflux control by antireflux surgery with the remainder receiving high dose proton pump inhibitor therapy. Ablation: ABPC was applied in longitudinal strips with mucosal bridges left between strips. Remaining Barrett's metaplasia was ablated at further sessions. All metaplasia was ablated to within 3cm of the gastro-esophageal junction. All procedures were carried out as day case procedures under intravenous sedation. Follow-up: To date, 1 patient has died of unrelated disease but the remaining patients have been followed by regular endoscopic surveillance for a mean of 3ys to give a total follow up of 144.1 patient years. No malignancy has developed in any patient during lbllow-up. Conclusion: This represents the longest reported follow-up after prophylactic ablation of long-segment Barrett's esophagus. The absence of malignant complications in all patients, including those with high-grade dysplasia strengthens the argument for endoscopic ablation in the prevention of esophageal adenocarcinoma.
"4122 A MODIFIED METHOD OF BOTULINUM B O X I N INJECTION IN PATIENTS WITH ACHALASIA MIGHT BE MORE EFFECTIVE THAN STANDARD ADMINISTRATION TECHNIQUE Jan Martinek, Eva Mecova, Julius Spicak, Clin of hepatogastroenterology, IKEM, Prague Czech Republic Background & aim: Injection of botulinum toxin into the lower esophageal sphincter (LES) is an effective treatment for achalasia. However, about 60% of patients experience a relapse within 6 months which requires further treatment. We hypothesized that better LES infiltration by toxin could improve the effect. The aim of this study was to investigate the efficacy of a modified method of intrasphincteric botulinum toxin injection in patients with achalasia. Patients and method: We treated 16 patients (mean age 46.1 yrs, range 24-73) with achalasia (12 patients with classic and 4 with vigorous achalasia). We diluted 100 units of botulinum toxin with 8 ml of normal saline. Thereafter we injected aliquots of 1 ml (12.5 units per milliliter of saline) into quadrants of the LES from retrovision and then into each quadrant from direct vision. The patients completed a questionnaire where they evaluated the degree of dysphagia and regurgitation on a visual analogue scale (measured on a scale from 1= none to 5= severe) before, 1 week, 3 and 8 months after treatment. We performed esophageal manometry before and 3 months after injection. Results: All patients responded well to treatment within one week after the injection. No patient had a relapse requiring treatment during the 8 months of follow-up. At 3 months, all treated patients were asymptomatie. At 8 months, 30% of patients reported a mild-to-moderate relapse of solid dysphagia. The mean (±SD) scores before, 3 and 8 months after the treatment were: solid dysphagia: 4.8 (0.4); 1.4 (0.6) and 2.9 (0.8); fluid dysphagia: 3.9 (1.2); 1.1 (0.3) and 1.7 (1.2); regurgitation: 3.7 (1.6); 1.2 (0.4) and 1.4 (1.1), respectively (p<0.05 before vs. after for all scores). The mean (±SD) basal LES pressure decreased from 45.3 (23.6) mmHg before to 28.3 (8.3) mmHg 3 months after treatment; the mean (±SD) percentage of LES relaxation increased from 50.4% (33) before to 75.7% (21) after treatment. Conclusion: Dividing the injection of botulinum toxin into two parts - 50 units injected from retrovision and direct vision each - produced a rapid response which was sustained for 8 months in the majority of treated patients. This technique of injection might be superior to standard injection from direct vision. We suggest a randomized trial comparing these two techniques of botulinum toxin administration should be performed.
VOLUME 53, NO. 5, 2001
GASTROINTESTINAL ENDOSCOPY
AB145