- Email: [email protected]
without intralesional steroids for benign gastroesophageal reflux strictures
ESOPHAGUS *245
*247
FLEXIBLE ENDOSCOPIC TREATMENT OF ZENKER'S DIVERTICULUM; A NEW APPROACH. C.J,J. Mulder, G. Den Hartog, R.J. Robijn, J.E. Thies. Gastroenterology, Rijnstate Hospital Arnhem, Central Hospital Apeldoorn, The Netherlands
RANDOMIZED TRIAL OF SAVARY DILATION WITH/WITHOUT INTRALESIONAL STEROIDS FOR BENIGN G A S T R O E S O P H A G E A L REFLUX STRICTURES. T. RueD, D. Earle, S. Ikenberry, L. Lumeng, G. Lehman, D i v i s i o n of Gastroenterology, Indiana U n i v e r s i t y Medical Center, Indianapolis, IN The typical management of peptic esophageal strictures ihcludes repeated lzfelong esophageal dilations and medical anti-reflux measures. A few reports indicate that c o r t i c o s t e r o i d in~ections facilitate stricture dilation. ~THODSI A randomxzed controlled single blind prospective study was undertaken, comparing the treatment of peptic esophageal strictures w i t h conventional Savary d i l a t i o n vs Savary dilation plus t r i a m c i n o l o n e acetonide (40 mg/ml) injection. Steroids were injected using a 25 gauge ~ 3 mm length eelerotherapy-type needle in O.S ml aliquots in each of 4 quadrants at the narrowest region of stricture. Steroid pts. were injected initially and at any subsequent dilation session(s} occuring ~30 days later (maximum 5 sessions}. Pts. entering the study underwent a b a r i u m esophagram, an upper endoscopy w i t h biopsy (to rule out malignancy), an esophageal m o t i l i t y study, ana an endoscopic u l t r a s o u n d to assess stricture thickness. Pts. were a s s i g n e d d y s p h a g i a scores (015) m o n t h l y by a blinded interviewer (Dig Dis sci 1988; 33:389-92}. (Score 15 = no dysphagia, score O = total dys~hagia.) All pts. were instructed on a general anti-reflux regimen and g i v e n omeprazole 20 mg daily for a weeks then famotldine 20 mg twice daily continuously. Pts. were scheduled to return weekly u n t i l a 51 Fr dilator was ~assed; thereafter, pts. r e t u r n e d on a prn basis. Repeat endoscop[ and d i l a t i o n ith/wlthout steroid injection} were encourages if the dyspha ia score dropped below I0. RESULTS: ~
A Zenker's diverticulum (ZD) is a posterior herniation of the hypopharyngeal mucosa between the cricopharyngeal sphincter and the inferior constrictor muscles. Serious oropharyngeal dysphagia may develop, usually progressive over a period of years. The treatment of Z D consists of transcervical diverticulectomy or rigid endoscopic therapy (ENT). Principle of endoscopic treatment is to divide the tissue-bridge between oesophagus and ZD; an overflow from diverticulum to oesophagus will be achieved. Sixteen patients with a ZD 4 females and 12 males, with a mean age of 79 yrs: range 68-92 yrs, have been treated between January 1993 August 1994. After introduction of a flexible gastroscope a nasogastric tube was positioned with the help of a guidewire. With guiding of the nasogastric tube (14-16F) the tissue-bridge of the ZD becomes more pronounced and was divided through monopolar biopsy coagulation (MTW, Valley Lab cut/coag 50/30 Watts) with a flexible gastroscope (Olympus K10, VI00). All patients received prophylactic antibiotics. Average number of treatments was 3 with a minimum of l and a maximum of 12. Treatment was successful with a good symptomatic response in all subjects. The mean depth of the ZD was 7 cm. Follow-up endoscopy revealed no fibrosis and scar tissue after 6 and 12 months in our first nine patients. The results of our pilot study are promising, however it took 12 procedures to treat the patient with a very large ZD (12cm). All 16 patients were very satisfied with the results obtained. Symptoms of dysphagia were gone after treatment. No severe complications were recognized. Three patients complained about a sore throat for 1-3 days. We conclude that the treatment of Zenker's diverticulum with a flexible gastroscope is a relative easy method. The mean number of procedures has probably been influenced by our learning curve. A very important advantage of endoscopic treatment is that it can be carried out in patients whose general health is poor. By using a flexible gastroscope our technique seems possible in every intervention endoscopy unit.
Study Group
n 22
Mean Follow-up (Months) 13.2
Additional Dilations/Mon~ Follow-up 0,070"
Mean Monthly Dy~hagia Sc,om Pr~Post 5.9/14.4
Dil + S~roids Dilation'Alone
21
10.1
0.253*
6.9/10.3
*p < 0 . 0 0 1
SgMMARyt There are less frequent dilations and better dysphsgia scores in steroid t r e a t e d pts. CONCLUSION: The technique is simple and should be c o n s i d e r e d for general use.
%246
t248
BAND LIGATION VS SCLEROTHERAPY FOR THE TREATMENT OF BLEEDING ESOPHAGEAL VARICES: A META-ANALYSIS AND COST ANALYSIS. H.P. Patel, M.D. Hughes, F.L Weber Jr. Division of Digestive Diseases, Universityof Cincinna~,Cincinnati,OH
PALLIATION OF PARTIALLY OBSTRUCTING ESOPHAGEAL CARCINOMAWITH PHOTODYNAMICTHERAPu DScheider. M Siemens, G Haber, G Kandel, P Kortan, N Marcon. The Wellesley Hospital, Toronto, Canada. Backuround: Between 1987 and 1994, 92 pts with partially obstructing esophageal carcinoma and dysphagia were treated with photodynamic therapy (PDT). Treatment included injection of PHOTOFRIN" (porfimer sodium) 2mg/kg, and irradiation with a 630rim laser light dose of 300J/cm. POT was the primary treatment in 38 (42%), and 54 had received other prior treatment including surgery, radiation, chemotherapy, and Nd:YAG laser. The pts ranged from 37 to 91 years (median= 70.6 yrs; 75% M). Histologically 37% were squamous cell carcinoma, 62% were adenocarcinoma (AC), and 1% were small cell carcinoma. Tumor sizes were <4cm in 38%, 4-8cm in 47%, and >8cm in 14%. Pt dysphagia grade (DG), using a 1-5 scale, ranged from DG 2, d~culty with solids to DG 4, difficulty with liquids. Results: At the 1 month follow-up, dysphagia improved o o in 66.3%, worsened in 9.0%, and remained unchanged in 24.7%. Only 1 PDT course was given in 70%, 2 in 18.5%, and >__33in 12%. Following PDT, 47 pts received secondary therapy, including 27 for stenting. Mean survival was 205 days (range 21 to 1541 days), with 9 pts alive at foUow-up. Mean survival of pts with AC of the esophagus was significantly better compared to AC of the cardia (p=0.001). Mean survival of patients treated with PDT initially was significantly better compared to those previously treated with other modalities .C.oncus on PDT is an effective method of palliation for malignant dysphagia in extensive disease or debilitated pts. PDT is a viable alternative to the traditional palliation methods of surgery or radiation.
Althoughthe few randomizedcontrolledtrials comparing band ligation (BL) and sclerotherapy(S) for bleedingesophagealvarices have favored band ligation, these studies did not consistently find significant differences for several importantoutcomes.A meta-analysiswas performedto define those outcomes wheresignificantdifferencesbetweenBL and S existed. Method=: All publishedrandomizedcontrolledtrials comparing BL to S for the treatment of bleeding esophagealvarices from Jan.1989 to Sept.1994 were used in our analysis.Three published studies fulfilled our inclusion criteria, h meta-analysisusingTrue Epistatcomputeranalysissoftwarewas performedfor the control of acute bleedingfrom esophagealvarices, reduction in recurrent bleeding,complica~onsassociatedwith each treatmentmodalityand numberof endoscopictherapies requiredfor eradication of esophagealvarices. A cost analysis was performed for reNeeding, major keatment complications, and eradicationof esophagealvaricesbetween8L and S. Results: Our meta-analysisincluded 158 patients in the BL treatment group and 151 patientsin the S group.Therewas no significantdifference betweenthe two b'eatmentgroups in the control of acute esophagealvariceal hemorrhage. The incidenceof rebleedingin the BL groupwas significantlylowerwith an odds ratio of 0.63 (95% confidence intervals/el/; 0.48 to 0.83). The number of complicationsassociatedwith BL was also significantlylower with an odds ratio of 0.34 (95% CI; 0.18 to 0.61). The BL group also requiredfewer endoscopic treatment sessions to eradicateesophagealvarices (mean: BL=3.8 sessions, S=5.3 sessions). Substantialcostsavingswere realizedin the BL group. Conclusions: Band ligation and sclerotherapy are equally effective in the trea~nent of acute esophagealvariceal bleeding.Band ligation requiresfewer endoscopicsessionsto eradicateesophagealvariceswith fewer complications and with a reducedrisk of rebleedingduringthe courseof therapy. Substantial cost savingswould he realizedin the bandligationgroup due to the more rapid eradication of esophageal varices, fewer procedures required to treat complicationsand 1/3 fewer admissionsfor acuterebleeding.
V O L U M E 41, N O . 4, 1995
GASTROINTESTINAL
ENDOSCOPY
357
*247
FLEXIBLE ENDOSCOPIC TREATMENT OF ZENKER'S DIVERTICULUM; A NEW APPROACH. C.J,J. Mulder, G. Den Hartog, R.J. Robijn, J.E. Thies. Gastroenterology, Rijnstate Hospital Arnhem, Central Hospital Apeldoorn, The Netherlands
RANDOMIZED TRIAL OF SAVARY DILATION WITH/WITHOUT INTRALESIONAL STEROIDS FOR BENIGN G A S T R O E S O P H A G E A L REFLUX STRICTURES. T. RueD, D. Earle, S. Ikenberry, L. Lumeng, G. Lehman, D i v i s i o n of Gastroenterology, Indiana U n i v e r s i t y Medical Center, Indianapolis, IN The typical management of peptic esophageal strictures ihcludes repeated lzfelong esophageal dilations and medical anti-reflux measures. A few reports indicate that c o r t i c o s t e r o i d in~ections facilitate stricture dilation. ~THODSI A randomxzed controlled single blind prospective study was undertaken, comparing the treatment of peptic esophageal strictures w i t h conventional Savary d i l a t i o n vs Savary dilation plus t r i a m c i n o l o n e acetonide (40 mg/ml) injection. Steroids were injected using a 25 gauge ~ 3 mm length eelerotherapy-type needle in O.S ml aliquots in each of 4 quadrants at the narrowest region of stricture. Steroid pts. were injected initially and at any subsequent dilation session(s} occuring ~30 days later (maximum 5 sessions}. Pts. entering the study underwent a b a r i u m esophagram, an upper endoscopy w i t h biopsy (to rule out malignancy), an esophageal m o t i l i t y study, ana an endoscopic u l t r a s o u n d to assess stricture thickness. Pts. were a s s i g n e d d y s p h a g i a scores (015) m o n t h l y by a blinded interviewer (Dig Dis sci 1988; 33:389-92}. (Score 15 = no dysphagia, score O = total dys~hagia.) All pts. were instructed on a general anti-reflux regimen and g i v e n omeprazole 20 mg daily for a weeks then famotldine 20 mg twice daily continuously. Pts. were scheduled to return weekly u n t i l a 51 Fr dilator was ~assed; thereafter, pts. r e t u r n e d on a prn basis. Repeat endoscop[ and d i l a t i o n ith/wlthout steroid injection} were encourages if the dyspha ia score dropped below I0. RESULTS: ~
A Zenker's diverticulum (ZD) is a posterior herniation of the hypopharyngeal mucosa between the cricopharyngeal sphincter and the inferior constrictor muscles. Serious oropharyngeal dysphagia may develop, usually progressive over a period of years. The treatment of Z D consists of transcervical diverticulectomy or rigid endoscopic therapy (ENT). Principle of endoscopic treatment is to divide the tissue-bridge between oesophagus and ZD; an overflow from diverticulum to oesophagus will be achieved. Sixteen patients with a ZD 4 females and 12 males, with a mean age of 79 yrs: range 68-92 yrs, have been treated between January 1993 August 1994. After introduction of a flexible gastroscope a nasogastric tube was positioned with the help of a guidewire. With guiding of the nasogastric tube (14-16F) the tissue-bridge of the ZD becomes more pronounced and was divided through monopolar biopsy coagulation (MTW, Valley Lab cut/coag 50/30 Watts) with a flexible gastroscope (Olympus K10, VI00). All patients received prophylactic antibiotics. Average number of treatments was 3 with a minimum of l and a maximum of 12. Treatment was successful with a good symptomatic response in all subjects. The mean depth of the ZD was 7 cm. Follow-up endoscopy revealed no fibrosis and scar tissue after 6 and 12 months in our first nine patients. The results of our pilot study are promising, however it took 12 procedures to treat the patient with a very large ZD (12cm). All 16 patients were very satisfied with the results obtained. Symptoms of dysphagia were gone after treatment. No severe complications were recognized. Three patients complained about a sore throat for 1-3 days. We conclude that the treatment of Zenker's diverticulum with a flexible gastroscope is a relative easy method. The mean number of procedures has probably been influenced by our learning curve. A very important advantage of endoscopic treatment is that it can be carried out in patients whose general health is poor. By using a flexible gastroscope our technique seems possible in every intervention endoscopy unit.
Study Group
n 22
Mean Follow-up (Months) 13.2
Additional Dilations/Mon~ Follow-up 0,070"
Mean Monthly Dy~hagia Sc,om Pr~Post 5.9/14.4
Dil + S~roids Dilation'Alone
21
10.1
0.253*
6.9/10.3
*p < 0 . 0 0 1
SgMMARyt There are less frequent dilations and better dysphsgia scores in steroid t r e a t e d pts. CONCLUSION: The technique is simple and should be c o n s i d e r e d for general use.
%246
t248
BAND LIGATION VS SCLEROTHERAPY FOR THE TREATMENT OF BLEEDING ESOPHAGEAL VARICES: A META-ANALYSIS AND COST ANALYSIS. H.P. Patel, M.D. Hughes, F.L Weber Jr. Division of Digestive Diseases, Universityof Cincinna~,Cincinnati,OH
PALLIATION OF PARTIALLY OBSTRUCTING ESOPHAGEAL CARCINOMAWITH PHOTODYNAMICTHERAPu DScheider. M Siemens, G Haber, G Kandel, P Kortan, N Marcon. The Wellesley Hospital, Toronto, Canada. Backuround: Between 1987 and 1994, 92 pts with partially obstructing esophageal carcinoma and dysphagia were treated with photodynamic therapy (PDT). Treatment included injection of PHOTOFRIN" (porfimer sodium) 2mg/kg, and irradiation with a 630rim laser light dose of 300J/cm. POT was the primary treatment in 38 (42%), and 54 had received other prior treatment including surgery, radiation, chemotherapy, and Nd:YAG laser. The pts ranged from 37 to 91 years (median= 70.6 yrs; 75% M). Histologically 37% were squamous cell carcinoma, 62% were adenocarcinoma (AC), and 1% were small cell carcinoma. Tumor sizes were <4cm in 38%, 4-8cm in 47%, and >8cm in 14%. Pt dysphagia grade (DG), using a 1-5 scale, ranged from DG 2, d~culty with solids to DG 4, difficulty with liquids. Results: At the 1 month follow-up, dysphagia improved o o in 66.3%, worsened in 9.0%, and remained unchanged in 24.7%. Only 1 PDT course was given in 70%, 2 in 18.5%, and >__33in 12%. Following PDT, 47 pts received secondary therapy, including 27 for stenting. Mean survival was 205 days (range 21 to 1541 days), with 9 pts alive at foUow-up. Mean survival of pts with AC of the esophagus was significantly better compared to AC of the cardia (p=0.001). Mean survival of patients treated with PDT initially was significantly better compared to those previously treated with other modalities .C.oncus on PDT is an effective method of palliation for malignant dysphagia in extensive disease or debilitated pts. PDT is a viable alternative to the traditional palliation methods of surgery or radiation.
Althoughthe few randomizedcontrolledtrials comparing band ligation (BL) and sclerotherapy(S) for bleedingesophagealvarices have favored band ligation, these studies did not consistently find significant differences for several importantoutcomes.A meta-analysiswas performedto define those outcomes wheresignificantdifferencesbetweenBL and S existed. Method=: All publishedrandomizedcontrolledtrials comparing BL to S for the treatment of bleeding esophagealvarices from Jan.1989 to Sept.1994 were used in our analysis.Three published studies fulfilled our inclusion criteria, h meta-analysisusingTrue Epistatcomputeranalysissoftwarewas performedfor the control of acute bleedingfrom esophagealvarices, reduction in recurrent bleeding,complica~onsassociatedwith each treatmentmodalityand numberof endoscopictherapies requiredfor eradication of esophagealvarices. A cost analysis was performed for reNeeding, major keatment complications, and eradicationof esophagealvaricesbetween8L and S. Results: Our meta-analysisincluded 158 patients in the BL treatment group and 151 patientsin the S group.Therewas no significantdifference betweenthe two b'eatmentgroups in the control of acute esophagealvariceal hemorrhage. The incidenceof rebleedingin the BL groupwas significantlylowerwith an odds ratio of 0.63 (95% confidence intervals/el/; 0.48 to 0.83). The number of complicationsassociatedwith BL was also significantlylower with an odds ratio of 0.34 (95% CI; 0.18 to 0.61). The BL group also requiredfewer endoscopic treatment sessions to eradicateesophagealvarices (mean: BL=3.8 sessions, S=5.3 sessions). Substantialcostsavingswere realizedin the BL group. Conclusions: Band ligation and sclerotherapy are equally effective in the trea~nent of acute esophagealvariceal bleeding.Band ligation requiresfewer endoscopicsessionsto eradicateesophagealvariceswith fewer complications and with a reducedrisk of rebleedingduringthe courseof therapy. Substantial cost savingswould he realizedin the bandligationgroup due to the more rapid eradication of esophageal varices, fewer procedures required to treat complicationsand 1/3 fewer admissionsfor acuterebleeding.
V O L U M E 41, N O . 4, 1995
GASTROINTESTINAL
ENDOSCOPY
357