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Radio Frequency Endoscopic Anti-Reflux (STRETTA) Procedure for the Tratment of Refractory GERD in Elderly Patients
Abstracts
S1217 Radio Frequency Endoscopic Anti-Reflux (STRETTA) Procedure for the Tratment of Refractory GERD in Elderly Patients Herbert Wolfsen, Lois Hemminger Purpose: Age-related changes in the esophagus include altered motility and sensitivity to acid reflux. Elderly patients with acid reflux symptoms refractory to medical therapy represent a difficult clinical management challenge. Methods: After IRB approval, we reviewed the records of patients O65 years old who have undergone the Stretta procedure. Our Stretta clinical protocol requires documentation of GERD by ambulatory esophageal pH testing. Endoscopy is required to rule out Barrett’s disease, severe esophagitis or large hiatal hernia. All patients undergo esophageal motility testing and laparoscopic surgery consultation to discuss fundoplication. These patients were contacted to update their current symptom status and use of medications. We inquired about procedure complications, medication use and current symptoms. Results: Since January 2001, we have treated 13 patients (7 women) with the Stretta endoscopic anti-reflux device. Follow up information was available on 11/13 patients (85%). The median patient age was 71 years (range 67-75). Median time since Stretta was 21 months (range 841). No patients reported any treatment complications or new symptoms after Stretta. None had subsequently undergone other endoscopic or surgical reflux treatment. All patients were using twice daily PPI C/ÿ bedtime H2RA. At follow up, 4 patients were off medication, 1 patient was using ‘‘prn’’ H2RA or PPI, daily PPI was used in 5 patients and twice daily PPI was still used in 1 patient. Conclusions: In this limited study of elderly patients over age 65 years with medically refractory acid reflux disease, treatment with the Stretta procedure was associated with decreased medication use in most patients (10/11). No treatment complications or new symptoms had developed nearly 2 years, median, after Stretta. In our experience, Stretta has been useful in the management of these difficult patients.
S1219 The Findings of Upper Gastrointestinal Endoscopy Before and After the Living-Donor Liver Transplantation: Reflux Esophagitis Is the Frequent Complication after the Transplantation Masashi Yoshida, Tomotaka Akatsu, Motohide Shimazu, Go Wakabayashi, Minoru Tanabe, Shigeyuki Kawachi, Hideki Ishikawa, Tetsuya Nakamura, Koichiro Kumai, Tetsuro Kubota, Yoshihide Otani, Yoshiro Saikawa, Masaki Kitajima Portal hypertension, stress induced by operation, immunosupressive agents, and Helicobacter pylori may affect the findings of upper gastrointestinal endoscopy before and after the liver transplantation. Relatively small graft is one of characteristics of living-donor liver transplantation. The effects of living-donor liver transplantation on upper gastrointestinal endoscopic finding have not been examined well. Patients and Methods: Twenty-eight adult patients underwent livingdonor liver transplantation were included in the present study. Upper gastrointestinal endoscopy was performed in 20 patients before and 22 patients after the transplantation. Results: Esophageal varix was seen in all of 18 cases with liver cirrhosis before transplantation. All of them were disappeared after transplantation. Portal hypertensive gastropathy was positive in 65% of patients. Twelve patients were classified as mild and one patient was classified as severe (McCormack’s classification). According to Toyonaga’s classification, 8 patients were classified as grade 1 and 4 patients were classified as grade 2. All of them were disappeared after the transplantation. Only 1 patient (5.0%) had grade A (Los Angeles classification) esophagitis before the transplantation. However, 6 out of 22 (27.3%) patients (grade C: 2, grade B: 1, grade A: 1, discoloring type: 2) had reflux esophagitis after the transplantation. Two patients had gastric or duodenal ulcer before the transplantation, however, no patient suffered from gastric nor duodenal ulcer after the transplantation. Before the transplantation, Helicobacter pylori positive rate was 33.3% (3/9). After the transplantation, only 1 out of 21 (4.8%) patients were Helicobacter pylori positive by culture of the gastric mucosa. Number of isolated bacteria by general microbiological culture of the gastric mucosa was not increased in the patients after the transplantation compared with control patients. Conclusion: The living-donor liver transplantation had curative effects on esophageal varix and portal hypertensive gastropathy. However, reflux esophagitis was a complication encountered following liver transplantation. Helicobacter pylori positive rate was low in the patients after the liver transplantation.
S1220 Eosinophilic Esophagitis or Asthma of the Esophagus: First Case Series Report From Chile Rodrigo Zapata, M. Olivero, Pedro Aponte, Roque Saenz, Claudio Navarrete, Marcela Schultz, Yumai Pires S1218 Influence of Hepatocellular Function on Rebleeding and Variceal Recurrence After Esophageal Variceal Ligation in Liver Cirrhosis Stephen N. Wong, Melchor M. Chan, Albert Ismael, Evan Ong, Jose Tan, Marvin Basco, Jose D. Sollano Background: Poor liver function is associated with an increased incidence of variceal hemorrhage. However, it is not clear whether the severity of liver dysfunction can influence significant clinical endpoints after successful eradication of esophageal varices (EV) by endoscopic variceal ligation (EVL). The objective of this study is to determine whether rebleeding and variceal recurrence rates are influenced by the Child-Pugh classification (CPC) in cirrhotic patients who underwent successful EVL. Methods: Seventy consecutive cirrhotic patients who underwent EVL for an episode of variceal bleeding from March 2001 to April 2004 were included. EVL was repeated at 7 day intervals until all EV were obliterated. Follow-up endoscopies were performed every 6 mos. thereafter. CPC scores were determined at baseline and at the time of rebleeding. Results: Mean age was 53.4 C 14.4 years with a male:female ratio of 3.7:1. Obliteration of EV was achieved in 1.7 C 0.8 EVL sessions in 59 (84.3%) patients. CPC distribution was as follows: CPC A Z 31.4%; CPC B Z 45.7%; and CPC C Z 22.9%. Mean follow-up was 12.4 C 9.9 mos. There was no correlation between CPC and EV recurrence rates at 24 mos. (CPC A Z 42.5% vs. B Z 52% vs. C Z 25%, p Z 0.99). Rebleeding rate at 24 mos. was significantly higher in CPC C (63.7%) as compared to CPC A and B, 29.8% and 38.7%, respectively (p Z 0.04). However, this difference did not hold when only patients with successful EV obliteration were included (p Z 0.76). Multivariate analysis revealed that failure to obliterate the EV was the lone independent predictor of rebleeding (p Z 0.01) while no factor was found to predict variceal recurrence. Conclusion: In cirrhotic patients who underwent EVL for variceal bleeding, the most important factor for the prevention of rebleeding is the successful obliteration of the EV. CPC scores have no influence on rebleeding and variceal recurrence rates after successful EV obliteration by EVL.
AB146 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
Introduction: Eosinophilic esophagitis (EE) is a recently described idiopathic clinico-patological entity seen mainly in children and young adults associated with recurrent disphagia and episodes of food impaction. It is characterized endoscopically by a ringed esophagus and histologically by a dense epithelial eosinophilic infiltration (O 24 eosinophils per high-power field) (HPF). Objectives: To describe the clinical, endoscopic and histopathological characteristics and therapy response of a cohort of Chilean adult patients with EE recently diagnosed in our Center. Methods: We describe 7 consecutive adult patients with EE seen at our Center between August 2003 and August 2004. During this period a total of 4356 upper GI endoscopies were performed due to many causes. Results: Of all upper GI endoscopies performed during 8/2003-8/2004, 0.16% (7/4356) had confirmed EE. Other 3 patients had endoscopic ringed esophagus with histopathology not confirming EE (0-3 eosinophils por HPF). All EE patients were men with a mean age of 34.7 years (range (22-58 years-old). 85.7% had dysphagia, 71.4% had previous episodes of solid food impaction and acid reflux was a common associated symptom (85.7%). None of them had history of atopy or asthma. 25.8% had peripheral eosinophilia and 42.8% had elevated IgE levels. The mean eosinophil infiltration of the biopsied esophageal mucosa was 56.4 (range 25-110 per HPF). In four cases the stomach was also biopsied without showing eosinophil infiltration of the mucosa. In 71.4% the skin tests showed evidence of allergies to different foods. Therapy included food restrictions (diet) and steroids (oral or inhaled/degluted). The response during the first 6-12 months has been variable with good overall response after steroids either topical or systemic. Conclusions: Eosinophilic esophagitis is an uncommon clinical entity associated with disphagia and recurrent episodes of solid-food impaction seen predominantly in young male adults. The knowledge of this entity may rise the clinical suspicion of this diagnosis in patients with recurrent esophageal symptoms prompting to biopsy the esophageal mucosa to demonstrate the typical dense infiltration of eosinophils. In our case series report 7/10 patients with an evident ringed esophagus seen out of 4356 upper GI endoscopies, had finally a confirmed EE. The therapy including diet restrictions and steroids (whether topical or systemic) may improve temporarily these symptoms.
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S1217 Radio Frequency Endoscopic Anti-Reflux (STRETTA) Procedure for the Tratment of Refractory GERD in Elderly Patients Herbert Wolfsen, Lois Hemminger Purpose: Age-related changes in the esophagus include altered motility and sensitivity to acid reflux. Elderly patients with acid reflux symptoms refractory to medical therapy represent a difficult clinical management challenge. Methods: After IRB approval, we reviewed the records of patients O65 years old who have undergone the Stretta procedure. Our Stretta clinical protocol requires documentation of GERD by ambulatory esophageal pH testing. Endoscopy is required to rule out Barrett’s disease, severe esophagitis or large hiatal hernia. All patients undergo esophageal motility testing and laparoscopic surgery consultation to discuss fundoplication. These patients were contacted to update their current symptom status and use of medications. We inquired about procedure complications, medication use and current symptoms. Results: Since January 2001, we have treated 13 patients (7 women) with the Stretta endoscopic anti-reflux device. Follow up information was available on 11/13 patients (85%). The median patient age was 71 years (range 67-75). Median time since Stretta was 21 months (range 841). No patients reported any treatment complications or new symptoms after Stretta. None had subsequently undergone other endoscopic or surgical reflux treatment. All patients were using twice daily PPI C/ÿ bedtime H2RA. At follow up, 4 patients were off medication, 1 patient was using ‘‘prn’’ H2RA or PPI, daily PPI was used in 5 patients and twice daily PPI was still used in 1 patient. Conclusions: In this limited study of elderly patients over age 65 years with medically refractory acid reflux disease, treatment with the Stretta procedure was associated with decreased medication use in most patients (10/11). No treatment complications or new symptoms had developed nearly 2 years, median, after Stretta. In our experience, Stretta has been useful in the management of these difficult patients.
S1219 The Findings of Upper Gastrointestinal Endoscopy Before and After the Living-Donor Liver Transplantation: Reflux Esophagitis Is the Frequent Complication after the Transplantation Masashi Yoshida, Tomotaka Akatsu, Motohide Shimazu, Go Wakabayashi, Minoru Tanabe, Shigeyuki Kawachi, Hideki Ishikawa, Tetsuya Nakamura, Koichiro Kumai, Tetsuro Kubota, Yoshihide Otani, Yoshiro Saikawa, Masaki Kitajima Portal hypertension, stress induced by operation, immunosupressive agents, and Helicobacter pylori may affect the findings of upper gastrointestinal endoscopy before and after the liver transplantation. Relatively small graft is one of characteristics of living-donor liver transplantation. The effects of living-donor liver transplantation on upper gastrointestinal endoscopic finding have not been examined well. Patients and Methods: Twenty-eight adult patients underwent livingdonor liver transplantation were included in the present study. Upper gastrointestinal endoscopy was performed in 20 patients before and 22 patients after the transplantation. Results: Esophageal varix was seen in all of 18 cases with liver cirrhosis before transplantation. All of them were disappeared after transplantation. Portal hypertensive gastropathy was positive in 65% of patients. Twelve patients were classified as mild and one patient was classified as severe (McCormack’s classification). According to Toyonaga’s classification, 8 patients were classified as grade 1 and 4 patients were classified as grade 2. All of them were disappeared after the transplantation. Only 1 patient (5.0%) had grade A (Los Angeles classification) esophagitis before the transplantation. However, 6 out of 22 (27.3%) patients (grade C: 2, grade B: 1, grade A: 1, discoloring type: 2) had reflux esophagitis after the transplantation. Two patients had gastric or duodenal ulcer before the transplantation, however, no patient suffered from gastric nor duodenal ulcer after the transplantation. Before the transplantation, Helicobacter pylori positive rate was 33.3% (3/9). After the transplantation, only 1 out of 21 (4.8%) patients were Helicobacter pylori positive by culture of the gastric mucosa. Number of isolated bacteria by general microbiological culture of the gastric mucosa was not increased in the patients after the transplantation compared with control patients. Conclusion: The living-donor liver transplantation had curative effects on esophageal varix and portal hypertensive gastropathy. However, reflux esophagitis was a complication encountered following liver transplantation. Helicobacter pylori positive rate was low in the patients after the liver transplantation.
S1220 Eosinophilic Esophagitis or Asthma of the Esophagus: First Case Series Report From Chile Rodrigo Zapata, M. Olivero, Pedro Aponte, Roque Saenz, Claudio Navarrete, Marcela Schultz, Yumai Pires S1218 Influence of Hepatocellular Function on Rebleeding and Variceal Recurrence After Esophageal Variceal Ligation in Liver Cirrhosis Stephen N. Wong, Melchor M. Chan, Albert Ismael, Evan Ong, Jose Tan, Marvin Basco, Jose D. Sollano Background: Poor liver function is associated with an increased incidence of variceal hemorrhage. However, it is not clear whether the severity of liver dysfunction can influence significant clinical endpoints after successful eradication of esophageal varices (EV) by endoscopic variceal ligation (EVL). The objective of this study is to determine whether rebleeding and variceal recurrence rates are influenced by the Child-Pugh classification (CPC) in cirrhotic patients who underwent successful EVL. Methods: Seventy consecutive cirrhotic patients who underwent EVL for an episode of variceal bleeding from March 2001 to April 2004 were included. EVL was repeated at 7 day intervals until all EV were obliterated. Follow-up endoscopies were performed every 6 mos. thereafter. CPC scores were determined at baseline and at the time of rebleeding. Results: Mean age was 53.4 C 14.4 years with a male:female ratio of 3.7:1. Obliteration of EV was achieved in 1.7 C 0.8 EVL sessions in 59 (84.3%) patients. CPC distribution was as follows: CPC A Z 31.4%; CPC B Z 45.7%; and CPC C Z 22.9%. Mean follow-up was 12.4 C 9.9 mos. There was no correlation between CPC and EV recurrence rates at 24 mos. (CPC A Z 42.5% vs. B Z 52% vs. C Z 25%, p Z 0.99). Rebleeding rate at 24 mos. was significantly higher in CPC C (63.7%) as compared to CPC A and B, 29.8% and 38.7%, respectively (p Z 0.04). However, this difference did not hold when only patients with successful EV obliteration were included (p Z 0.76). Multivariate analysis revealed that failure to obliterate the EV was the lone independent predictor of rebleeding (p Z 0.01) while no factor was found to predict variceal recurrence. Conclusion: In cirrhotic patients who underwent EVL for variceal bleeding, the most important factor for the prevention of rebleeding is the successful obliteration of the EV. CPC scores have no influence on rebleeding and variceal recurrence rates after successful EV obliteration by EVL.
AB146 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
Introduction: Eosinophilic esophagitis (EE) is a recently described idiopathic clinico-patological entity seen mainly in children and young adults associated with recurrent disphagia and episodes of food impaction. It is characterized endoscopically by a ringed esophagus and histologically by a dense epithelial eosinophilic infiltration (O 24 eosinophils per high-power field) (HPF). Objectives: To describe the clinical, endoscopic and histopathological characteristics and therapy response of a cohort of Chilean adult patients with EE recently diagnosed in our Center. Methods: We describe 7 consecutive adult patients with EE seen at our Center between August 2003 and August 2004. During this period a total of 4356 upper GI endoscopies were performed due to many causes. Results: Of all upper GI endoscopies performed during 8/2003-8/2004, 0.16% (7/4356) had confirmed EE. Other 3 patients had endoscopic ringed esophagus with histopathology not confirming EE (0-3 eosinophils por HPF). All EE patients were men with a mean age of 34.7 years (range (22-58 years-old). 85.7% had dysphagia, 71.4% had previous episodes of solid food impaction and acid reflux was a common associated symptom (85.7%). None of them had history of atopy or asthma. 25.8% had peripheral eosinophilia and 42.8% had elevated IgE levels. The mean eosinophil infiltration of the biopsied esophageal mucosa was 56.4 (range 25-110 per HPF). In four cases the stomach was also biopsied without showing eosinophil infiltration of the mucosa. In 71.4% the skin tests showed evidence of allergies to different foods. Therapy included food restrictions (diet) and steroids (oral or inhaled/degluted). The response during the first 6-12 months has been variable with good overall response after steroids either topical or systemic. Conclusions: Eosinophilic esophagitis is an uncommon clinical entity associated with disphagia and recurrent episodes of solid-food impaction seen predominantly in young male adults. The knowledge of this entity may rise the clinical suspicion of this diagnosis in patients with recurrent esophageal symptoms prompting to biopsy the esophageal mucosa to demonstrate the typical dense infiltration of eosinophils. In our case series report 7/10 patients with an evident ringed esophagus seen out of 4356 upper GI endoscopies, had finally a confirmed EE. The therapy including diet restrictions and steroids (whether topical or systemic) may improve temporarily these symptoms.
www.mosby.com/gie