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Pre-op documentation of gastroesophageal reflux (GER) does not predict long term outcome in children requiring feeding gastrostomy
A8
AGA ABSTRACTS
GASTROENTEROLOGY, Vol. 108, No. 4
• DIAGNOSIS-SPECIFIC PROCEDURE TIME, COMPLICATION RATE AND CLINICAL VALUE OF ENDOSCOPIC ULTRASOUND: A PRIVATE PRACTICE SETTING. MF C a ~ o , JE Geenen, GK Johnson, MJ Schmalz, L Jacob, DJ Geenen, A Ross, WJ Hogan. St. Luke's Hospital, Racine, Luke's Medical Center, Milwaukee, Wisconsin. Endoscopic ultrasonography (EUS) is becoming more commonly used as the diagnostic modality of choice for a variety of GI disorders. For many reasons, including prohibitive equipment expense, difficulty in mastering the technique and lack of tertiary referral, the use of EUS has been limited to academic centers. With the expanding role of EUS, its emergence into private practice has slowly occurred. The safety record, procedural difficulty and diagnostic usefulness in a private practice setting is unknown. AIM: To assess EUS clinical value, safety and procedure time according to specific diagnosis. METHODS: All pts undergoing EUS exams during an 18 month period were enrolled in the study. Procedure time (to assess relative value units), complications (not related to sedation) and clinical value (information not previously obtained by other diagnostic modality) were prospectively determined. RESULTS: PATIENT DIAGNOSIS
Pt
Time
(rag)
(mg)
Clinical Value
49.0
72.4
4.5
27 (100%)
12
44.5
68.5
3.7
12 (10075)
5
58.9
85.4
6.6
4 (809~)
14
55.3
82.8
5.9
12 (8695)
(e)
(rain)
Cancer staging*
27
Submueosaltumor Hepato-biliaryCA Pancreatic CA
Demerol Versed
Pancreatic Dis** 227 52.7 76.2 5.1 2O2 (89~) [*] sophageal/gastrie/ There were no significant EUS-related procedural complications. EUS procedure time for a variety of diagnoses ranged from a mean of 44.5 58.9 rain. Usefulness of EUS for all diagnoses ranged from 80-100%. CONCLUSIONS: The relative value units for EUS varied by procedural diagnoses, but generally approached 1 hr in all cases. This suggests that reimbursement should be similar to that obtained for colonoscopy and ERCP. Despite time constraints in private praetive, EUS is an important diagnostic adjunct to the practicing gastroenterologist.
r~-OP
F~ICT
DOCUMENTATIONOF C~,ST~OESOI~ACF~LREFLUX (GER) DOES NOT
LONG ~
OUTCOI~ IN' CHIIDL~ RP.QUI~TBG I~EDI~G
GASTROSTOMY. G. Che~imskv, M. Yrygier, M.W.L. Gauderer, J.T. Boyle. Dept. of Pediatrics, CWRU, Rainbow Babies & Childrens Hospltal, Cleveland, Ohio. Gastrostomy feedings can improve nutritional status in children with feeding difficulties and malnutrition associated wlthneurologic disorders and chronic cardiopulmonary disease (bronchopulmonary dysplasla, congenltal heart disease). Due to the high incidence of GER in this patient population, we determined if documentation of GER at the time of initial gastrostomy predicted long term outcome. A retrospective review was conducted on 69 patients (ages 1 mth to 6.2 yrs., mean 1.5 yrs) who underwent percutaneous endoscopic gastrostomy (PEG) based on tolerating 4-6 weeks of nasogastrlc (NG) feedings without unmasking complications of GER. Pre-op diagnosis of G E R w a s established by standard 24-hour ~H probe study criteria. Histological signs of reflux esophagitis were determined from biopsies obtained at the time of PEG placement. Management of GER consisted of proklnetic and/or acld-reducing drugs. Study variables included pre-op clinical symptoms of GER, pH probe results, and esophageal histology. Outcome variables included persistent clinical symptoms, long term drug therapy, and subsequent need for antl-reflux surgery. RESULTS: (i) Pre-PEG, 56% of patients had clinical symptoms of GER, 41% positive pH probe, and 31% histological esophagltis. (2) Follow-up information (mean, 2.6 yrs) revealed that 22% of patients had persistent clinical symptoms, 59% required chronic medication, and 9% underwent subsequent fundopllcatlon. (3) No significant difference in the incidence of any outcome variable was observed in patients with a positive study variable compared to patients without that variable (chi square). (4) When examined by underlying diagnosis, comparable incidence of each outcome variable were observed in patients with neurologic (39 pts.) and cardiopulmonary disorder (30 pts.). As with the entire study population, no study variable predicted any of the outcome variables in either group. CONCLUSION: Clinical, laboratory, or pathological documentation of GE~ prior to gastrostomy placement in pediatric patients with feeding difficulties does not predict long term outcome of GER. Use of such parameters in a care path to determine the need for a "protective" antireflux operation in children requiring feeding gastrostomies is not Justified.
• A YEAR AFTER THE NIH CONSENSUS STATEM~I~T ON ERADICATION OF H.PYLORI IN PEPTIC ULCER DISEASE, HOW BEST TO DO ZT? T.C. Chalmers, S.D.Ross, G.Neil, J.Lau, B.Kupelnlck and G. Whiting. MetaWorke Inc., T~fts-New England Medical Center, Boston, Mass., and Astra/Msrck Group, Wayne,Pa. The consensus statement recomaended eradication of H. Pylori in peptic ulcer patients but gave no data on the most effective regimens. The number of drugs and combinations of drug regimens tested in RCTs of H. Pylorl eradication in peptic ulcer patients presents a serious challenge to all gastroenterologists. We report the use of a system for adding series of patients in RCTs to matrices that facilitate performance of cumulative mete-analyses of selected treatment regimens. The following data illustrate the problem: Totals Year of publication <1992
1993
1994
abstracts* papers abe. pap. abe. pap. Publications 1 i0 4 6 5 ii Comparisons 3 15 6 8 5 18 Patients 30 580 199 268 450 923 *not yet followed by full papers The complexity of the large numbers is compounded by the variety of drugs, dose regimens and time and methods of assessing disappearance of H. Pylori, and the side effects and cost of each regimen. On the assumption that these variables will average out, and recognizing that the only effective method of handling the situation would be hierarchical multiple regression techniques (and there are not yet enough studies and patients for tha~) we have pooled the response rates in randomized duodenal ulcer patients: treatment response rates treat, response rates Num. Mean t C.I.** Num. Mean C.Z. placebo 1 5.3% .9-19 ome÷emox 6 87% 80"-92 omepra. 8 19.4% 15~25 mist.dual 5 35% 2 6 - 4 5 H2block. 9 9 . 7 % 6-15 trip+gme~ 7 87% 83-91 trip+his 8 79% 74~84 misc. trip. 3 61% 51-70 * weighted, random effects means ** 95~ Conf. Interv. In conclusion, constant monitoring of exemplary RCTs will be n e c e s s a r y to ensure that each patient receives optimal treatment of their H. P y l o r i .
NORTH-SOUTH GASTRIC CANCER AND DUODENAL ULCER DISEASE GRADIENTS IN CHINA. ~C.K.Chi0g, ~S.K.Lain, 2B.W.Chen, 2Y.N.Li, 2B.E.Wang, :Z.T.Zheng, 3Z.L.Li, aH.J.Liu, 5J.B.Liu, 5S.Z.Yuan, 6C.P.Xu, 7J.K.Zhang, SA.T.Zhang. Depts. of Medicine, University of 1Hong Kong, 2Beijing, 3Xian, 4Shanghai, SGuangzhou, 6Chongqing, 7Wuhan, SHarbin, China. We evaluated the frequencies of gastric cancer (GC), and peptic ulcer disease (PUD) rates over a 10-year period in 8 major cities of China. Endoscopy and case records between year 1977-1986 were examined. The annual total number of endoscopies, duodenal ulcer, gastric ulcer, and confirmed gastric cancer together With the patients' age and sex were recorded. The results were pooled together. T test was used to compare the PUD or GC rate between the *north and the **south China regions. Results Prevalence/1000 endoscopies DU GU Total PU GC DU:GU *Heilongjiang40 64 104 76.5 0.62 *Xian 96 60 156 72.0 1.45 *Shanghai 113 118 231 53.9 0.96 *Beijing 143 65 208 23.9 2.19 North, mea,q 98 76.__88 174.8 56.6 1.30 **Chongqing 209 145 354 59.7 1.44 **Wuhan 192 95 287 48.9 2.02 **Guangzhou 242 77.5 319.5 21.8 3.12 **Hong Kong 317 77 394 6.0 4.10 South, mean 240 98.6 338,6 34.1 2.70 North vs south China p 0.007 0.341 0.004 0.238 0.102 There was a linear inverse relationship between the GC prevalence and DU rate (r=-0.8076, p=0.015), and DU:GU ratio (r=-0.9133, p =0,002). Concl0~ions DU but not GU was significantly more frequent in the south China than in the north. The reverse was true for GC. There were significantly higher GC rates in areas with lower DU rate and DU:GU ratio. Since the Hp frequency is similar in north & south China (Ching et al. J. Gastroenterol. Heaptol. 1994;9:$4-7), other factors are likely to be involved to explain the disparity in DU & GC rates in these regions.
AGA ABSTRACTS
GASTROENTEROLOGY, Vol. 108, No. 4
• DIAGNOSIS-SPECIFIC PROCEDURE TIME, COMPLICATION RATE AND CLINICAL VALUE OF ENDOSCOPIC ULTRASOUND: A PRIVATE PRACTICE SETTING. MF C a ~ o , JE Geenen, GK Johnson, MJ Schmalz, L Jacob, DJ Geenen, A Ross, WJ Hogan. St. Luke's Hospital, Racine, Luke's Medical Center, Milwaukee, Wisconsin. Endoscopic ultrasonography (EUS) is becoming more commonly used as the diagnostic modality of choice for a variety of GI disorders. For many reasons, including prohibitive equipment expense, difficulty in mastering the technique and lack of tertiary referral, the use of EUS has been limited to academic centers. With the expanding role of EUS, its emergence into private practice has slowly occurred. The safety record, procedural difficulty and diagnostic usefulness in a private practice setting is unknown. AIM: To assess EUS clinical value, safety and procedure time according to specific diagnosis. METHODS: All pts undergoing EUS exams during an 18 month period were enrolled in the study. Procedure time (to assess relative value units), complications (not related to sedation) and clinical value (information not previously obtained by other diagnostic modality) were prospectively determined. RESULTS: PATIENT DIAGNOSIS
Pt
Time
(rag)
(mg)
Clinical Value
49.0
72.4
4.5
27 (100%)
12
44.5
68.5
3.7
12 (10075)
5
58.9
85.4
6.6
4 (809~)
14
55.3
82.8
5.9
12 (8695)
(e)
(rain)
Cancer staging*
27
Submueosaltumor Hepato-biliaryCA Pancreatic CA
Demerol Versed
Pancreatic Dis** 227 52.7 76.2 5.1 2O2 (89~) [*] sophageal/gastrie/ There were no significant EUS-related procedural complications. EUS procedure time for a variety of diagnoses ranged from a mean of 44.5 58.9 rain. Usefulness of EUS for all diagnoses ranged from 80-100%. CONCLUSIONS: The relative value units for EUS varied by procedural diagnoses, but generally approached 1 hr in all cases. This suggests that reimbursement should be similar to that obtained for colonoscopy and ERCP. Despite time constraints in private praetive, EUS is an important diagnostic adjunct to the practicing gastroenterologist.
r~-OP
F~ICT
DOCUMENTATIONOF C~,ST~OESOI~ACF~LREFLUX (GER) DOES NOT
LONG ~
OUTCOI~ IN' CHIIDL~ RP.QUI~TBG I~EDI~G
GASTROSTOMY. G. Che~imskv, M. Yrygier, M.W.L. Gauderer, J.T. Boyle. Dept. of Pediatrics, CWRU, Rainbow Babies & Childrens Hospltal, Cleveland, Ohio. Gastrostomy feedings can improve nutritional status in children with feeding difficulties and malnutrition associated wlthneurologic disorders and chronic cardiopulmonary disease (bronchopulmonary dysplasla, congenltal heart disease). Due to the high incidence of GER in this patient population, we determined if documentation of GER at the time of initial gastrostomy predicted long term outcome. A retrospective review was conducted on 69 patients (ages 1 mth to 6.2 yrs., mean 1.5 yrs) who underwent percutaneous endoscopic gastrostomy (PEG) based on tolerating 4-6 weeks of nasogastrlc (NG) feedings without unmasking complications of GER. Pre-op diagnosis of G E R w a s established by standard 24-hour ~H probe study criteria. Histological signs of reflux esophagitis were determined from biopsies obtained at the time of PEG placement. Management of GER consisted of proklnetic and/or acld-reducing drugs. Study variables included pre-op clinical symptoms of GER, pH probe results, and esophageal histology. Outcome variables included persistent clinical symptoms, long term drug therapy, and subsequent need for antl-reflux surgery. RESULTS: (i) Pre-PEG, 56% of patients had clinical symptoms of GER, 41% positive pH probe, and 31% histological esophagltis. (2) Follow-up information (mean, 2.6 yrs) revealed that 22% of patients had persistent clinical symptoms, 59% required chronic medication, and 9% underwent subsequent fundopllcatlon. (3) No significant difference in the incidence of any outcome variable was observed in patients with a positive study variable compared to patients without that variable (chi square). (4) When examined by underlying diagnosis, comparable incidence of each outcome variable were observed in patients with neurologic (39 pts.) and cardiopulmonary disorder (30 pts.). As with the entire study population, no study variable predicted any of the outcome variables in either group. CONCLUSION: Clinical, laboratory, or pathological documentation of GE~ prior to gastrostomy placement in pediatric patients with feeding difficulties does not predict long term outcome of GER. Use of such parameters in a care path to determine the need for a "protective" antireflux operation in children requiring feeding gastrostomies is not Justified.
• A YEAR AFTER THE NIH CONSENSUS STATEM~I~T ON ERADICATION OF H.PYLORI IN PEPTIC ULCER DISEASE, HOW BEST TO DO ZT? T.C. Chalmers, S.D.Ross, G.Neil, J.Lau, B.Kupelnlck and G. Whiting. MetaWorke Inc., T~fts-New England Medical Center, Boston, Mass., and Astra/Msrck Group, Wayne,Pa. The consensus statement recomaended eradication of H. Pylori in peptic ulcer patients but gave no data on the most effective regimens. The number of drugs and combinations of drug regimens tested in RCTs of H. Pylorl eradication in peptic ulcer patients presents a serious challenge to all gastroenterologists. We report the use of a system for adding series of patients in RCTs to matrices that facilitate performance of cumulative mete-analyses of selected treatment regimens. The following data illustrate the problem: Totals Year of publication <1992
1993
1994
abstracts* papers abe. pap. abe. pap. Publications 1 i0 4 6 5 ii Comparisons 3 15 6 8 5 18 Patients 30 580 199 268 450 923 *not yet followed by full papers The complexity of the large numbers is compounded by the variety of drugs, dose regimens and time and methods of assessing disappearance of H. Pylori, and the side effects and cost of each regimen. On the assumption that these variables will average out, and recognizing that the only effective method of handling the situation would be hierarchical multiple regression techniques (and there are not yet enough studies and patients for tha~) we have pooled the response rates in randomized duodenal ulcer patients: treatment response rates treat, response rates Num. Mean t C.I.** Num. Mean C.Z. placebo 1 5.3% .9-19 ome÷emox 6 87% 80"-92 omepra. 8 19.4% 15~25 mist.dual 5 35% 2 6 - 4 5 H2block. 9 9 . 7 % 6-15 trip+gme~ 7 87% 83-91 trip+his 8 79% 74~84 misc. trip. 3 61% 51-70 * weighted, random effects means ** 95~ Conf. Interv. In conclusion, constant monitoring of exemplary RCTs will be n e c e s s a r y to ensure that each patient receives optimal treatment of their H. P y l o r i .
NORTH-SOUTH GASTRIC CANCER AND DUODENAL ULCER DISEASE GRADIENTS IN CHINA. ~C.K.Chi0g, ~S.K.Lain, 2B.W.Chen, 2Y.N.Li, 2B.E.Wang, :Z.T.Zheng, 3Z.L.Li, aH.J.Liu, 5J.B.Liu, 5S.Z.Yuan, 6C.P.Xu, 7J.K.Zhang, SA.T.Zhang. Depts. of Medicine, University of 1Hong Kong, 2Beijing, 3Xian, 4Shanghai, SGuangzhou, 6Chongqing, 7Wuhan, SHarbin, China. We evaluated the frequencies of gastric cancer (GC), and peptic ulcer disease (PUD) rates over a 10-year period in 8 major cities of China. Endoscopy and case records between year 1977-1986 were examined. The annual total number of endoscopies, duodenal ulcer, gastric ulcer, and confirmed gastric cancer together With the patients' age and sex were recorded. The results were pooled together. T test was used to compare the PUD or GC rate between the *north and the **south China regions. Results Prevalence/1000 endoscopies DU GU Total PU GC DU:GU *Heilongjiang40 64 104 76.5 0.62 *Xian 96 60 156 72.0 1.45 *Shanghai 113 118 231 53.9 0.96 *Beijing 143 65 208 23.9 2.19 North, mea,q 98 76.__88 174.8 56.6 1.30 **Chongqing 209 145 354 59.7 1.44 **Wuhan 192 95 287 48.9 2.02 **Guangzhou 242 77.5 319.5 21.8 3.12 **Hong Kong 317 77 394 6.0 4.10 South, mean 240 98.6 338,6 34.1 2.70 North vs south China p 0.007 0.341 0.004 0.238 0.102 There was a linear inverse relationship between the GC prevalence and DU rate (r=-0.8076, p=0.015), and DU:GU ratio (r=-0.9133, p =0,002). Concl0~ions DU but not GU was significantly more frequent in the south China than in the north. The reverse was true for GC. There were significantly higher GC rates in areas with lower DU rate and DU:GU ratio. Since the Hp frequency is similar in north & south China (Ching et al. J. Gastroenterol. Heaptol. 1994;9:$4-7), other factors are likely to be involved to explain the disparity in DU & GC rates in these regions.