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Routine use of fluoroscopic guidance for maloney esophageal dilation does impact on patient outcome
ESOPHAG US ?237
239
NOW DOES CHANGE IN C O N C E N T R A T I O N OF E S O P H A G E A L VARICEAL SCLEROTHERAPY AGENTS IMPACT ON P A T I E N T OUTCOME? SA McClave SN Gallo, WF Jones, RA Wright, MA Sagatelian, A Minocha, FD Manela, Dept. of Med, Univ of Louisville, Louisville, KY. INTRO: Increasing the c o n c e n t r a t i o n of e s o p h a g e a l variceal sclerotherapy (EVS) agents should improve e f f i c a c y (control of index bleed, rate of obliteration, and i n c i d e n c e of rebleeding) at the expense of p o t e n t i a l l y i n c r e a s i n g complications (rate of ulceration and stricture formation). We designed this study to evaluate the specific effect of change in concentration of two commonly used EVS agents, s o d i u m tetradecyl sulfate (STS) and sodium m o r r h u a t e (MOR), on patient outcome in an EVS program. METHODS: C i r r h o t i c patients with "index" esophageal variceal b l e e d i n g w e r e included in this study. Two groups of patients w e r e studied in sequential fashion. Initially, the first group (Grp A) was randomized to dilute concentrations of either STS (0.75%) or M O R (1.6%). Subsequently, the second group (Grp B) w a s randomized to higher concentrations of e i t h e r STS (1.5%) or M O R (2.5%). Concentrations were achieved by m i x i n g w i t h D~. EVS was done w e e k l y x 3, then m o n t h l y t h e r e a f t e r t o o b l i t e r a t i o n . Analysis was done by Fieher's Exact and M a n n - W h i t n e y U tests. RESULTS: Of 41 patients in Grp A (mean age 51.8 yrs, 38M/3F, Child's A/B/C - 10/23/8), 21 were r a n d o m i z e d to STD 0.75% and 20 to M O R 1.6%. Of 18 patients in G r p B (mean age 48.5, 13M/5F, child's A/B/C - 6/6/6), 8 were r a n d o m i z e d to STD 1.5% and i0 to M O R 2.5%. Results shown on table b e l o w (*p S 0.02):
MULTIPLE ESOPHAGEAL RINGS: AN ATYPICAL MANIFESTATION OF GASTROESOPHAGEAL REFLUX DISEASE? M. McKinley, T. Eisner, M Fisher, R. Bronzo, G. Weissman. Division of Gastroenterology, North Shore University HospitaI-Comell University Medical College.
EFFICACY/COMPLICATIONS Ctrl index bleed O b l i t e r a t i o n overall (in study > 3 mos) Sessions to oblit Mortality Rebleeding Transfused units/pt
0.75% Grp A (21)
STS ~ 1.5% Grp B (8)
85.7% 28.6% (87.0%) 7.5 38.1% 80.9% 8.3
i00.0% 25.0% (100%) 5.0 62.5% 75.O% 7.9
MOR 1.6% ~ 2.5% Grp A Grp E (20) (10) 90.0% 90.0% 20.0% 50.0% (83.0%)(83.3%) 11.5 8.2 25.O% 4O.0% 50.0% 70.0% 8.75 9.0
Ulceration 52.4% 37.5% 40.0% 60.0% Stricture 9.5% 25.0%* 0.0% 30.0%* 1.0 7.0 0.0 5.0 Dilations/pt CONCLUSIONS: While havin, little e f f e c t on overall efficacy, change in concentration of EVS agents had the greatest impact on the rate of stricture formation. These results suggest that the optimum concentrations of these two agents are the more dilute STD 0.75% and MOR 1.6%, w h i c h achieve c o m p a r a b l e effic a c y with significantly lower rates of s t r i c t u r e formation.
Single esophageal rings or webs are common. Multiple rings throughout the esophagus are rarely seen. To date, eight cases in the adult population have been reported, with complications following dilatation in two patients. We describe seven patients discovered to have multiple esophageal rings on endoscopy. The rings involved the entire esophagus, did not disappear with insufflation and were easily palpated with the tip of the endoscope. Endoscopic biopsies were performed in all patients. Esophageal motility and prolonged pH recordings were available in three patients. None of our patients had, a history of heartburn or anemia. All seven patients had a history of dysphagia. Six were mate, one was female. They ranged in age from 25-66 years. Six of the seven had a history of asthma. All the patients had histologic evidence of esophagitis, with two patients having a Barrett's esophagus. Three patients underwent esophageal motility studies, that demonstrated either a hypotensive LES or non-specific esophageal motility disorder. Ambulatory 24-hour pH monitoring revealed significant acid reflux, despite the absence of symptoms. The etiology of multiple esophageal rings is uncertain. We propose it is a distinct clinical entity related to gastroesophageal reflux, as demonstrated by histology, pH probe and the high incidence of asthma. Care should be taken when attempting dilatation in these patients, as transient bleeding was noted in two patients after through the scope balloon dilatation. Like asthma, we would suggest that multiple rings are an atypical manifestation of gastroesophageal reflux disease that is found in patients without a history of heartburn.
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240
ROUTINE USE OF F L U O R O S C O P I C G U I D A N C E FOR M A L O N E Y ESOPHAGEAL DILATION DOES IMPACT ON P A T I E N T OUTCOME. SA McClave, PG Brady, RA Wright, S Goldschmid, A Minocha. Depts of Medicine, Univ of Louisville, Univ of S. Florida, and Emory Univ; INTRO: Use of fluoroscopy for M a l o n e y e s o p h a g e a l dilation is controversial. We designed this p r o s p e c t i v e , randomized, single-blinded, multicenter study to d e t e r m i n e whether routine use of fluoroscopic guidance truly impacts on ultimate patient outcome as m e a s u r e d by relief of dysphagia and achievement of lumenal patency. METHODS: Patients referred for M a l o n e y d i l a t i o n with benign e s o p h a g e a l s t r i c t u r e s w e r e r a n d o m i z e d to u n d e r g o dilation with or without f l u o r o s c o p i c guidance. Strictures were c o n f i r m e d by failure of a 12.5 ram b a r i u m pill to pass through the esophagus in 20 sec (at a 45 ~ angle, 30-60 cc water). Patients underwent d i l a t i o n by a el staff physician up to size 48 French, then were r e - e v a l u a t e d by passage of a barium pill p o s t - d i l a t i o n by a OI fellow b l i n d e d to the technique used. Patients were r e - r a n d o m i z e d for subsequent sessions. Dysphagia scores (range 1-5) were o b t a i n e d pre-and one w e e k post-dilation. Student's t, chi-square, and critical ratios tests were used for analysis. RESULTS: Eighty-three patients were entered in the study and underwent a total of i00 d i l a t i o n s e s s i o n s - f l u o r o s c o p i c guidance being used for 50 sessions (156 dilations), blinded technique for 50 (161 dilations). Overall, the b a r i u m pill passed post-dilation following 62.0% (31/50) of the fluoroscopic dilation sessions, and 42.0% (21/50) of the blinded dilations (p < 0.05). D y s p h a g i a was improved in 93.0% (38/41) of those patients receiving fluoroscopic dilations, and 69.0% (29/42) of t h o s e p a t i e n t s receiving blinded dilations (p=0.006). The m e a n improvement in dysphagia score was 2.10 points for the fluoro group versus 1.50 points for the blinded group (p=0.057). Twelve patients were randomized to both t e c h n i q u e s at 27 different sessions. When fluoroscopic g u i d a n c e w a s used, the pill passed post-dilation following 50% (6/12) of the sessions, and dysphagia was improved in 100% (9/9). In the same patients using blinded technique, the pill p a s s e d postdilation following 6.7% (1/15) of the sessions (p=0.025), a n d dysphagia w a s improved f o l l o w i n g 22% (2/9) (p < 0.01). The mean improvement in d y s p h a g i a score for this subset of patients was 2.77 when fluoroscopy was used versus 0.22 when it was not (p=0.035). CONCLUSIONS: R o u t i n e use of fluoroscopic guidance does impact on u l t i m a t e patient outcome, as evidenced by g r e a t e r relief of d y s p h a g i a and increased lumenal patency compared to b l i n d e d technique. Based on the results of this study, use of fluoroscopy is recommended when performing M a l o n e y e s o p h a g e a l dilation.
A NOVEL APPLIANCE FOR SENGSTAKEN-BLAKEMORE TUBE POSITIONING. R.M. McMahon C. V. Netchvolodoff. Division of Gastroenterology, Univ. of Arkansas Medical Sciences, Little Rock, An, M. Gompertz. Univ. Tennessee, Memphis, TN
V O L U M E 41, NO. 4, 1995
PURPOSE: We proposed a novel, easily fabricated appliance to secure passive traction which is superior to active traction, taping, or traditional football helmet. SUMMARY: Balloon tamponade of esophageal varices has limited application. Patients may have Sengstaken-BlakemorefMinnesota (SBT) tubes in place during transfer from another facility, and such tubes are useful when alternate therapy (sclerotherepy, vasopressin infusion, or TIPS) has been unsuccessful. Approximation of the gastric balloon to varices is maintained with "passive traction". "Active traction" can pull the balloon up into the airway if the gastric balloon deflates. Taping to the nose or mouth or using a f~3tball helmet to secure the external end cf the SBT provides "passive traction", and orthoped;c traction pulley is an example of "active traction". The football helmet interferes with assessment and care of the patient and can hinder mechanical ventilation. It may be difficult to store and locate quickly. The amount of traction is difficult to gauge and maintain with taping to the nose or mouth, and pressure necrosis may result from use for longer than a few hours. RESULTS: We fabricated a novel appliance to secure "passive traction". The appliance is made from thermoplastic material used in occupational therapy for external splinting. It allows easy access to the patient's head, face and mouth, and can be stored in a "crash cart" drawer. Pressure is distributed over the forehead and maxilla, and a projection allows the SET to be secured. The appliance avoids excess pressure on the nose or mouth. CONCLUSION: We have fabricated a superior appliance to provide passive traction for Sengstaken-Blakemore tubes.
GASTROINTESTINAL ENDOSCOPY
355
239
NOW DOES CHANGE IN C O N C E N T R A T I O N OF E S O P H A G E A L VARICEAL SCLEROTHERAPY AGENTS IMPACT ON P A T I E N T OUTCOME? SA McClave SN Gallo, WF Jones, RA Wright, MA Sagatelian, A Minocha, FD Manela, Dept. of Med, Univ of Louisville, Louisville, KY. INTRO: Increasing the c o n c e n t r a t i o n of e s o p h a g e a l variceal sclerotherapy (EVS) agents should improve e f f i c a c y (control of index bleed, rate of obliteration, and i n c i d e n c e of rebleeding) at the expense of p o t e n t i a l l y i n c r e a s i n g complications (rate of ulceration and stricture formation). We designed this study to evaluate the specific effect of change in concentration of two commonly used EVS agents, s o d i u m tetradecyl sulfate (STS) and sodium m o r r h u a t e (MOR), on patient outcome in an EVS program. METHODS: C i r r h o t i c patients with "index" esophageal variceal b l e e d i n g w e r e included in this study. Two groups of patients w e r e studied in sequential fashion. Initially, the first group (Grp A) was randomized to dilute concentrations of either STS (0.75%) or M O R (1.6%). Subsequently, the second group (Grp B) w a s randomized to higher concentrations of e i t h e r STS (1.5%) or M O R (2.5%). Concentrations were achieved by m i x i n g w i t h D~. EVS was done w e e k l y x 3, then m o n t h l y t h e r e a f t e r t o o b l i t e r a t i o n . Analysis was done by Fieher's Exact and M a n n - W h i t n e y U tests. RESULTS: Of 41 patients in Grp A (mean age 51.8 yrs, 38M/3F, Child's A/B/C - 10/23/8), 21 were r a n d o m i z e d to STD 0.75% and 20 to M O R 1.6%. Of 18 patients in G r p B (mean age 48.5, 13M/5F, child's A/B/C - 6/6/6), 8 were r a n d o m i z e d to STD 1.5% and i0 to M O R 2.5%. Results shown on table b e l o w (*p S 0.02):
MULTIPLE ESOPHAGEAL RINGS: AN ATYPICAL MANIFESTATION OF GASTROESOPHAGEAL REFLUX DISEASE? M. McKinley, T. Eisner, M Fisher, R. Bronzo, G. Weissman. Division of Gastroenterology, North Shore University HospitaI-Comell University Medical College.
EFFICACY/COMPLICATIONS Ctrl index bleed O b l i t e r a t i o n overall (in study > 3 mos) Sessions to oblit Mortality Rebleeding Transfused units/pt
0.75% Grp A (21)
STS ~ 1.5% Grp B (8)
85.7% 28.6% (87.0%) 7.5 38.1% 80.9% 8.3
i00.0% 25.0% (100%) 5.0 62.5% 75.O% 7.9
MOR 1.6% ~ 2.5% Grp A Grp E (20) (10) 90.0% 90.0% 20.0% 50.0% (83.0%)(83.3%) 11.5 8.2 25.O% 4O.0% 50.0% 70.0% 8.75 9.0
Ulceration 52.4% 37.5% 40.0% 60.0% Stricture 9.5% 25.0%* 0.0% 30.0%* 1.0 7.0 0.0 5.0 Dilations/pt CONCLUSIONS: While havin, little e f f e c t on overall efficacy, change in concentration of EVS agents had the greatest impact on the rate of stricture formation. These results suggest that the optimum concentrations of these two agents are the more dilute STD 0.75% and MOR 1.6%, w h i c h achieve c o m p a r a b l e effic a c y with significantly lower rates of s t r i c t u r e formation.
Single esophageal rings or webs are common. Multiple rings throughout the esophagus are rarely seen. To date, eight cases in the adult population have been reported, with complications following dilatation in two patients. We describe seven patients discovered to have multiple esophageal rings on endoscopy. The rings involved the entire esophagus, did not disappear with insufflation and were easily palpated with the tip of the endoscope. Endoscopic biopsies were performed in all patients. Esophageal motility and prolonged pH recordings were available in three patients. None of our patients had, a history of heartburn or anemia. All seven patients had a history of dysphagia. Six were mate, one was female. They ranged in age from 25-66 years. Six of the seven had a history of asthma. All the patients had histologic evidence of esophagitis, with two patients having a Barrett's esophagus. Three patients underwent esophageal motility studies, that demonstrated either a hypotensive LES or non-specific esophageal motility disorder. Ambulatory 24-hour pH monitoring revealed significant acid reflux, despite the absence of symptoms. The etiology of multiple esophageal rings is uncertain. We propose it is a distinct clinical entity related to gastroesophageal reflux, as demonstrated by histology, pH probe and the high incidence of asthma. Care should be taken when attempting dilatation in these patients, as transient bleeding was noted in two patients after through the scope balloon dilatation. Like asthma, we would suggest that multiple rings are an atypical manifestation of gastroesophageal reflux disease that is found in patients without a history of heartburn.
*238
240
ROUTINE USE OF F L U O R O S C O P I C G U I D A N C E FOR M A L O N E Y ESOPHAGEAL DILATION DOES IMPACT ON P A T I E N T OUTCOME. SA McClave, PG Brady, RA Wright, S Goldschmid, A Minocha. Depts of Medicine, Univ of Louisville, Univ of S. Florida, and Emory Univ; INTRO: Use of fluoroscopy for M a l o n e y e s o p h a g e a l dilation is controversial. We designed this p r o s p e c t i v e , randomized, single-blinded, multicenter study to d e t e r m i n e whether routine use of fluoroscopic guidance truly impacts on ultimate patient outcome as m e a s u r e d by relief of dysphagia and achievement of lumenal patency. METHODS: Patients referred for M a l o n e y d i l a t i o n with benign e s o p h a g e a l s t r i c t u r e s w e r e r a n d o m i z e d to u n d e r g o dilation with or without f l u o r o s c o p i c guidance. Strictures were c o n f i r m e d by failure of a 12.5 ram b a r i u m pill to pass through the esophagus in 20 sec (at a 45 ~ angle, 30-60 cc water). Patients underwent d i l a t i o n by a el staff physician up to size 48 French, then were r e - e v a l u a t e d by passage of a barium pill p o s t - d i l a t i o n by a OI fellow b l i n d e d to the technique used. Patients were r e - r a n d o m i z e d for subsequent sessions. Dysphagia scores (range 1-5) were o b t a i n e d pre-and one w e e k post-dilation. Student's t, chi-square, and critical ratios tests were used for analysis. RESULTS: Eighty-three patients were entered in the study and underwent a total of i00 d i l a t i o n s e s s i o n s - f l u o r o s c o p i c guidance being used for 50 sessions (156 dilations), blinded technique for 50 (161 dilations). Overall, the b a r i u m pill passed post-dilation following 62.0% (31/50) of the fluoroscopic dilation sessions, and 42.0% (21/50) of the blinded dilations (p < 0.05). D y s p h a g i a was improved in 93.0% (38/41) of those patients receiving fluoroscopic dilations, and 69.0% (29/42) of t h o s e p a t i e n t s receiving blinded dilations (p=0.006). The m e a n improvement in dysphagia score was 2.10 points for the fluoro group versus 1.50 points for the blinded group (p=0.057). Twelve patients were randomized to both t e c h n i q u e s at 27 different sessions. When fluoroscopic g u i d a n c e w a s used, the pill passed post-dilation following 50% (6/12) of the sessions, and dysphagia was improved in 100% (9/9). In the same patients using blinded technique, the pill p a s s e d postdilation following 6.7% (1/15) of the sessions (p=0.025), a n d dysphagia w a s improved f o l l o w i n g 22% (2/9) (p < 0.01). The mean improvement in d y s p h a g i a score for this subset of patients was 2.77 when fluoroscopy was used versus 0.22 when it was not (p=0.035). CONCLUSIONS: R o u t i n e use of fluoroscopic guidance does impact on u l t i m a t e patient outcome, as evidenced by g r e a t e r relief of d y s p h a g i a and increased lumenal patency compared to b l i n d e d technique. Based on the results of this study, use of fluoroscopy is recommended when performing M a l o n e y e s o p h a g e a l dilation.
A NOVEL APPLIANCE FOR SENGSTAKEN-BLAKEMORE TUBE POSITIONING. R.M. McMahon C. V. Netchvolodoff. Division of Gastroenterology, Univ. of Arkansas Medical Sciences, Little Rock, An, M. Gompertz. Univ. Tennessee, Memphis, TN
V O L U M E 41, NO. 4, 1995
PURPOSE: We proposed a novel, easily fabricated appliance to secure passive traction which is superior to active traction, taping, or traditional football helmet. SUMMARY: Balloon tamponade of esophageal varices has limited application. Patients may have Sengstaken-BlakemorefMinnesota (SBT) tubes in place during transfer from another facility, and such tubes are useful when alternate therapy (sclerotherepy, vasopressin infusion, or TIPS) has been unsuccessful. Approximation of the gastric balloon to varices is maintained with "passive traction". "Active traction" can pull the balloon up into the airway if the gastric balloon deflates. Taping to the nose or mouth or using a f~3tball helmet to secure the external end cf the SBT provides "passive traction", and orthoped;c traction pulley is an example of "active traction". The football helmet interferes with assessment and care of the patient and can hinder mechanical ventilation. It may be difficult to store and locate quickly. The amount of traction is difficult to gauge and maintain with taping to the nose or mouth, and pressure necrosis may result from use for longer than a few hours. RESULTS: We fabricated a novel appliance to secure "passive traction". The appliance is made from thermoplastic material used in occupational therapy for external splinting. It allows easy access to the patient's head, face and mouth, and can be stored in a "crash cart" drawer. Pressure is distributed over the forehead and maxilla, and a projection allows the SET to be secured. The appliance avoids excess pressure on the nose or mouth. CONCLUSION: We have fabricated a superior appliance to provide passive traction for Sengstaken-Blakemore tubes.
GASTROINTESTINAL ENDOSCOPY
355