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or Intramucosal Carcinoma
Abstracts
higher in US and Western Europe in comparison to less developed countries. The aim of the study was to assess the prevalence of BE and BE-related neoplasia in unselected patients undergoing esophago-gastro-duodenoscopy (EGD) in single endoscopy unit in Poland. Material and Methods: All consecutive EGD reports from January 2005 to December 2007 were analyzed, including demographic data, EGD indications and endoscopic findings. Montreal classification definitions were used. Overall 6414 EGDs were included (54% females; median age 56 years, IQ range 45 to 68). Results: The diagnosis of endoscopically suspected esophageal metaplasia (ESEM) was made in 452 of 6414 EGDs (7.0%). In 5.3% of patients this was a new diagnosis and in remaining 1.7% EGD was done for BE surveillance. There was a significant increase during the study years in relative ESEM frequencies, both overall (5.5%, 6.4%, and 9.7% in 2005, 2006 and 2007, respectively, p!0.0001) and as a new diagnosis (4.2%, 5.2%, 7.0%, respectively, p!0.0001). ESEM was found more frequently when GERD was an indication for EGD (11% vs. 4% for other indications, p!0.0001) in males vs. females (9% vs. 5%, p!0.0001), in patients O36 years vs. younger (8% vs. 5%, pZ0.001), and in patients with hiatal hernia (27% vs. 5%, p!0.0001). The median ESEM length was 10 mm (IQ range 7 to 20), and 19% of ESEM segments were long (30 mm or more). Standardized random biopsies were taken from ESEM in 325 cases. The specialized intestinal metaplasia (SIM) was found in 51.5% of ESEM. The frequency of SIM also increased over study years (42%, 44%, and 65% respectively, pZ0.001). SIM was more frequent in patients O41 years vs. younger (56% vs. 26%, pZ0.0001) and in patients with length of ESEM O20 mm vs. shorter (67% vs. 47%, pZ0.005). However, SIM was significantly less frequent in patients in whom GERD was the indication for EGD vs. other indications (34% vs. 50%, pZ0.02). The prevalence of intraepithelial neoplasia (IN) - low-grade or high-grade IN and cancer - was low (5.8% of ESEM) with only three cases of HGD (0.9%) and one cancer (0.3%). IN was more frequent in patients O57 years vs. younger (11% vs. 1%; p!0.0001), with previously diagnosed BE (16% vs. 2%; p!0.0001) and in patients with length of ESEM O 45 mm (20% vs. 4%; pZ0.008). Conclusions: The frequency of diagnosis of BE shows increasing tendency, but the prevalence of BE-related neoplasia in Central Europe is low. The risk of IN is highest in elderly patients with previously diagnosed long segment BE.
W1364 Photodynamic Therapy Followed By Radiofrequency Ablation for Treatment of Barrett’s Esophagus with High-Grade Dysplasia and/or Intramucosal Carcinoma Patrick S. Yachimski, William P. Puricelli, Norman S. Nishioka Introduction: Photodynamic therapy (PDT) with porfimer sodium and radiofrequency ablation (RFA) are both primary treatment modalities for Barrett’s esophagus (BE) with high-grade dysplasia. Sequential use of PDT and RFA has not been reported. The aim of this study was to examine the efficacy and safety of RFA in patients who had previously undergone PDT of BE with high-grade dysplasia (HGD) and/or intramucosal carcinoma (IMC). Methods: This was a retrospective study at a tertiary referral center. An institutional dataset of patients who had undergone PDT for treatment of BE was reviewed and a subset of patients who had undergone both PDT and subsequent RFA was identified. Endoscopy reports, pathology reports and the medical record were reviewed to extract additional clinical and demographic data. Results: The final cohort consisted of 17 patients. Porfimer sodium PDT was the initial ablation modality in all cases, with a mean of 1.1 (range 1-2) PDT sessions performed per patient. 12 subjects were male and 5 female, with a mean age of 68.9 10.7 yrs and mean BMI of 27.9 4.1 at initiation of ablation therapy. Mean length of BE pre-PDT was 6.6 3.2 cm. Pre-PDT pathology was HGD in 53% of patients (9/17) and IMC in 47% of patients (8/17). One patient developed a post-PDT stricture. RFA was performed with a Halo90 device (BARRX Medical, Sunnyvale CA, USA), with a mean of 1.5 (range 1-3) RFA sessions per patient, and a mean of 781 (range 138-2492) days between completion of PDT and initial RFA. Mean length of BE pre-RFA was 3.2 4.4 cm. Pre-RFA pathology was persistent IMC in 12% (2/17), persistent HGD in 41% (7/17), and nondsyplastic BE in 47% (8/17). Post-RFA pathology was available for 15 patients. Ablation of all HGD/IMC was documented in 87% of patients post-RFA (13/15), and ablation of all BE was documented in 60% of patients post-RFA (9/15). Among 8 patients with persistent HGD following PDT, ablation of HGD/IMC was achieved in 75% (6/8) and ablation of all BE was achieved in 63% (5/8) post-RFA. Among 7 patients with nondysplastic BE following PDT, ablation of all BE was achieved in 57% (4/7) post-RFA. One patient with a stricture prior to RFA had a persistent stricture post-RFA, and dilation of this stricture resulted in transmural esophageal perforation. No other strictures were identified following RFA. Conclusions: Among patients with refractory BE with or without dysplasia following porfimer sodium PDT, additional treatment with RFA can result in high rates of eradication of dysplastic and nondysplastic BE, and restitution with neosquamous epithelium.
W1365 Causes for Reintervention After Esophageal Stent Placement: A Single Center Experience Aravind Sugumar, Todd H. Baron Background: Esophageal stents are increasingly used in clinical practice for various benign and malignant conditions. There is very little literature on the re intervention rates after stent placement. We sought to examine symptoms and need
AB352 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
for re intervention after esophageal stent placement. Methods: We retrospectively reviewed the records of all patients who underwent esophageal stent placement at Mayo Clinic, Rochester from Jan. 1st 2001 to Dec. 31 2006 (NZ276). 32 patients required reintervention. Data abstracted included type of stent, diameter, location of placement, reason for re intervention and duration to stent migration or removal. We divided complications into immediate (within 2 days) early (within one month) and late (after 1 month). Results: 32 of 276 patients who had esophageal stents placed had endoscopic re intervention. There were 24 men (75%) and 8 women (25%). The most common reason for stent placement was esophageal carcinoma (84%). 65% of the stents were placed proximally while 40% were distally. There were a total of 84 reinterventions performed. Each patient who underwent an intervention had a mean of 2.69 procedures (range Z 2-11). The most common cause for reintervention was stent migration (nZ51) followed by tumor ingrowth (nZ25). Stent breakage (nZ3) and bleeding(nZ5) were uncommon reasons for reintervention. The most common symptom necessitating reintervention was recurrent dysphagia (80%), chest pain (60%) and GERD symptoms (55%). The most common immediate complication was maldeployment (20%) followed by delivery system entrapment (8%) and chest pain/dysphagia needing admission (7%). Airway compromise during procedure was uncommon (2%). The most common early complication/symptoms were nausea (80%), GERD (60%), vomiting (40%) aspiration pneumonia (13%). Bleeding (6%), food impaction (5%) and stent breakage (3%) were uncommon events. Late complications included GERD (40%) food impaction (6%), bleeding (6%) and tracheoesophageal fistula (5%). The mean time to intervention in these patients was 77 days with a range (1-226 days). Conclusion. Esophageal stent placement carries a 30% reintervention rate. Patients requiring reintervention tend to have more than one reason. Nausea, GERD and chest pain are the most common post-procedure symptoms. Perforation, bleeding and air way compromise are uncommon.
W1366 Clinical Remission in Endoscope-Guided Pneumatic Dilation for the Treatment of Esophageal Achalasia: 7-Year Follow-Up Results of a Prospective Investigation Seng-Kee Chuah, Chi-Sin Changchien, Wei-Chen Tai, Keng-Liang Wu Background: Prospective, long-term reports and predictors of outcome of endoscope-guided pneumatic dilation are lacking in the literature. We report the efficacy of endoscope-guided pneumatic dilation and determine the possible confounding factors related to remission. Methods: Between January 1998 to June 2004, 32 patients were enrolled. Each patient was treated with endoscope-guided pneumatic dilation and followed up at regular intervals for a median of 4.5 years. Remission was determined with the use of a structured interview and a previously described symptom score. Duration of remission was evaluated by Kaplan-Meier estimates of time to recurrence assessed before, and then 6 weeks, 6 months, 12 months and every year later. Possible confounding factors related to the remissions were analyzed by Cox’s proportional hazard model. Results: Complete follow-up until August 2007 was obtained in 100% of all patients. Cumulative remissions were 1 year (86.7%); 2 years (86.7%); 3 years (80.0%); 4 years (76.5%); 5 years (72.9%); 6 years (61.7%); and 7 years (61.7%) respectively. Age is a relevant confounding factor to the remissions showing a worse outcome for those under 45 (pZ0.046). One esophageal perforation occurred (3.3%). Conclusions: This prospective study showed that Endoscope-guided PD itself is safe and modestly effective for up to seven years investigations in current study. Older patients (O45 years) have a favorable overall clinical remissions. Keywords: Esophageal achalasia; endoscopeguided pneumatic dilation; clinical remissions; relevant confounding factors.
Figure 2.Overall remission rates of post-pneumatic dilatation in patients with esophageal achalasia
W1367 Endoscopic Treatment of Early Esophageal Cancer: Safety and Efficacy in An Early Training Stage Raf Bisschops, Ingrid Demedts, Gert De Hertogh, Philippe Nafteux, Antoon Lerut, Karel Geboes, Paul J. Rutgeerts Background: Endoscopic resection (ER) has become the treatment of choice for early mucosal well differentiated esophageal cancer (Pech et al 2008). Proper
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higher in US and Western Europe in comparison to less developed countries. The aim of the study was to assess the prevalence of BE and BE-related neoplasia in unselected patients undergoing esophago-gastro-duodenoscopy (EGD) in single endoscopy unit in Poland. Material and Methods: All consecutive EGD reports from January 2005 to December 2007 were analyzed, including demographic data, EGD indications and endoscopic findings. Montreal classification definitions were used. Overall 6414 EGDs were included (54% females; median age 56 years, IQ range 45 to 68). Results: The diagnosis of endoscopically suspected esophageal metaplasia (ESEM) was made in 452 of 6414 EGDs (7.0%). In 5.3% of patients this was a new diagnosis and in remaining 1.7% EGD was done for BE surveillance. There was a significant increase during the study years in relative ESEM frequencies, both overall (5.5%, 6.4%, and 9.7% in 2005, 2006 and 2007, respectively, p!0.0001) and as a new diagnosis (4.2%, 5.2%, 7.0%, respectively, p!0.0001). ESEM was found more frequently when GERD was an indication for EGD (11% vs. 4% for other indications, p!0.0001) in males vs. females (9% vs. 5%, p!0.0001), in patients O36 years vs. younger (8% vs. 5%, pZ0.001), and in patients with hiatal hernia (27% vs. 5%, p!0.0001). The median ESEM length was 10 mm (IQ range 7 to 20), and 19% of ESEM segments were long (30 mm or more). Standardized random biopsies were taken from ESEM in 325 cases. The specialized intestinal metaplasia (SIM) was found in 51.5% of ESEM. The frequency of SIM also increased over study years (42%, 44%, and 65% respectively, pZ0.001). SIM was more frequent in patients O41 years vs. younger (56% vs. 26%, pZ0.0001) and in patients with length of ESEM O20 mm vs. shorter (67% vs. 47%, pZ0.005). However, SIM was significantly less frequent in patients in whom GERD was the indication for EGD vs. other indications (34% vs. 50%, pZ0.02). The prevalence of intraepithelial neoplasia (IN) - low-grade or high-grade IN and cancer - was low (5.8% of ESEM) with only three cases of HGD (0.9%) and one cancer (0.3%). IN was more frequent in patients O57 years vs. younger (11% vs. 1%; p!0.0001), with previously diagnosed BE (16% vs. 2%; p!0.0001) and in patients with length of ESEM O 45 mm (20% vs. 4%; pZ0.008). Conclusions: The frequency of diagnosis of BE shows increasing tendency, but the prevalence of BE-related neoplasia in Central Europe is low. The risk of IN is highest in elderly patients with previously diagnosed long segment BE.
W1364 Photodynamic Therapy Followed By Radiofrequency Ablation for Treatment of Barrett’s Esophagus with High-Grade Dysplasia and/or Intramucosal Carcinoma Patrick S. Yachimski, William P. Puricelli, Norman S. Nishioka Introduction: Photodynamic therapy (PDT) with porfimer sodium and radiofrequency ablation (RFA) are both primary treatment modalities for Barrett’s esophagus (BE) with high-grade dysplasia. Sequential use of PDT and RFA has not been reported. The aim of this study was to examine the efficacy and safety of RFA in patients who had previously undergone PDT of BE with high-grade dysplasia (HGD) and/or intramucosal carcinoma (IMC). Methods: This was a retrospective study at a tertiary referral center. An institutional dataset of patients who had undergone PDT for treatment of BE was reviewed and a subset of patients who had undergone both PDT and subsequent RFA was identified. Endoscopy reports, pathology reports and the medical record were reviewed to extract additional clinical and demographic data. Results: The final cohort consisted of 17 patients. Porfimer sodium PDT was the initial ablation modality in all cases, with a mean of 1.1 (range 1-2) PDT sessions performed per patient. 12 subjects were male and 5 female, with a mean age of 68.9 10.7 yrs and mean BMI of 27.9 4.1 at initiation of ablation therapy. Mean length of BE pre-PDT was 6.6 3.2 cm. Pre-PDT pathology was HGD in 53% of patients (9/17) and IMC in 47% of patients (8/17). One patient developed a post-PDT stricture. RFA was performed with a Halo90 device (BARRX Medical, Sunnyvale CA, USA), with a mean of 1.5 (range 1-3) RFA sessions per patient, and a mean of 781 (range 138-2492) days between completion of PDT and initial RFA. Mean length of BE pre-RFA was 3.2 4.4 cm. Pre-RFA pathology was persistent IMC in 12% (2/17), persistent HGD in 41% (7/17), and nondsyplastic BE in 47% (8/17). Post-RFA pathology was available for 15 patients. Ablation of all HGD/IMC was documented in 87% of patients post-RFA (13/15), and ablation of all BE was documented in 60% of patients post-RFA (9/15). Among 8 patients with persistent HGD following PDT, ablation of HGD/IMC was achieved in 75% (6/8) and ablation of all BE was achieved in 63% (5/8) post-RFA. Among 7 patients with nondysplastic BE following PDT, ablation of all BE was achieved in 57% (4/7) post-RFA. One patient with a stricture prior to RFA had a persistent stricture post-RFA, and dilation of this stricture resulted in transmural esophageal perforation. No other strictures were identified following RFA. Conclusions: Among patients with refractory BE with or without dysplasia following porfimer sodium PDT, additional treatment with RFA can result in high rates of eradication of dysplastic and nondysplastic BE, and restitution with neosquamous epithelium.
W1365 Causes for Reintervention After Esophageal Stent Placement: A Single Center Experience Aravind Sugumar, Todd H. Baron Background: Esophageal stents are increasingly used in clinical practice for various benign and malignant conditions. There is very little literature on the re intervention rates after stent placement. We sought to examine symptoms and need
AB352 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
for re intervention after esophageal stent placement. Methods: We retrospectively reviewed the records of all patients who underwent esophageal stent placement at Mayo Clinic, Rochester from Jan. 1st 2001 to Dec. 31 2006 (NZ276). 32 patients required reintervention. Data abstracted included type of stent, diameter, location of placement, reason for re intervention and duration to stent migration or removal. We divided complications into immediate (within 2 days) early (within one month) and late (after 1 month). Results: 32 of 276 patients who had esophageal stents placed had endoscopic re intervention. There were 24 men (75%) and 8 women (25%). The most common reason for stent placement was esophageal carcinoma (84%). 65% of the stents were placed proximally while 40% were distally. There were a total of 84 reinterventions performed. Each patient who underwent an intervention had a mean of 2.69 procedures (range Z 2-11). The most common cause for reintervention was stent migration (nZ51) followed by tumor ingrowth (nZ25). Stent breakage (nZ3) and bleeding(nZ5) were uncommon reasons for reintervention. The most common symptom necessitating reintervention was recurrent dysphagia (80%), chest pain (60%) and GERD symptoms (55%). The most common immediate complication was maldeployment (20%) followed by delivery system entrapment (8%) and chest pain/dysphagia needing admission (7%). Airway compromise during procedure was uncommon (2%). The most common early complication/symptoms were nausea (80%), GERD (60%), vomiting (40%) aspiration pneumonia (13%). Bleeding (6%), food impaction (5%) and stent breakage (3%) were uncommon events. Late complications included GERD (40%) food impaction (6%), bleeding (6%) and tracheoesophageal fistula (5%). The mean time to intervention in these patients was 77 days with a range (1-226 days). Conclusion. Esophageal stent placement carries a 30% reintervention rate. Patients requiring reintervention tend to have more than one reason. Nausea, GERD and chest pain are the most common post-procedure symptoms. Perforation, bleeding and air way compromise are uncommon.
W1366 Clinical Remission in Endoscope-Guided Pneumatic Dilation for the Treatment of Esophageal Achalasia: 7-Year Follow-Up Results of a Prospective Investigation Seng-Kee Chuah, Chi-Sin Changchien, Wei-Chen Tai, Keng-Liang Wu Background: Prospective, long-term reports and predictors of outcome of endoscope-guided pneumatic dilation are lacking in the literature. We report the efficacy of endoscope-guided pneumatic dilation and determine the possible confounding factors related to remission. Methods: Between January 1998 to June 2004, 32 patients were enrolled. Each patient was treated with endoscope-guided pneumatic dilation and followed up at regular intervals for a median of 4.5 years. Remission was determined with the use of a structured interview and a previously described symptom score. Duration of remission was evaluated by Kaplan-Meier estimates of time to recurrence assessed before, and then 6 weeks, 6 months, 12 months and every year later. Possible confounding factors related to the remissions were analyzed by Cox’s proportional hazard model. Results: Complete follow-up until August 2007 was obtained in 100% of all patients. Cumulative remissions were 1 year (86.7%); 2 years (86.7%); 3 years (80.0%); 4 years (76.5%); 5 years (72.9%); 6 years (61.7%); and 7 years (61.7%) respectively. Age is a relevant confounding factor to the remissions showing a worse outcome for those under 45 (pZ0.046). One esophageal perforation occurred (3.3%). Conclusions: This prospective study showed that Endoscope-guided PD itself is safe and modestly effective for up to seven years investigations in current study. Older patients (O45 years) have a favorable overall clinical remissions. Keywords: Esophageal achalasia; endoscopeguided pneumatic dilation; clinical remissions; relevant confounding factors.
Figure 2.Overall remission rates of post-pneumatic dilatation in patients with esophageal achalasia
W1367 Endoscopic Treatment of Early Esophageal Cancer: Safety and Efficacy in An Early Training Stage Raf Bisschops, Ingrid Demedts, Gert De Hertogh, Philippe Nafteux, Antoon Lerut, Karel Geboes, Paul J. Rutgeerts Background: Endoscopic resection (ER) has become the treatment of choice for early mucosal well differentiated esophageal cancer (Pech et al 2008). Proper
www.giejournal.org