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S1475: Endoscopic Variceal Ligation (EVL) Alone Versus Endoscopic Variceal Ligation Plus Propranolol in Variceal Bleeding Prophylaxis in Cirrhotic Patients
Abstracts reach the bilioenteric limb occurred in 4/29 patients (13.7%). Of the subsequent 25 patients, 3 patients needed additional surgical revision of their anastomoses leading to an overall success rate of ES in HAS patients of 88% (22/25). 24 % of patients needed repeat endoscopic procedures due to restenosis (6/25).Overall complication rate was 13.79% (n⫽4), all successfully resolved and split equally between minor bleeding status post cautery or injection of saline and cardiopulmonary distress status post resuscitation or intubation. Conclusion: The development of strictures status post hepaticojejunostomies is a serious and common post-operative complication. We describe an innovative and effective endoscopic approach to the management of HAS. It is a single session procedure that does not mandate stenting. Complication rates are minimal, suggesting ES may be a safe alternative to more invasive traditional therapies.
S1472 SpyGlass® Peroral Cholangioscopy System for Visual Differentiation and Optically Guided Tissue Sample Biopsy of Biliary Strictures: A Single-Center Preliminary Observational Study Dimitrios Xinopoulos, Stefanos P. Bassioukas, Dimitrios Kypreos, Dimitrios Dimitroulopoulos, Dimitris P. Korkolis, Klisthenis Tsamakidis, Argyro Loukou, Apostolos Poulakis, Emmanuil Paraskevas Introduction: Appropriate endoscopic or and surgical treatment of biliary strictures mainly depends on the accuracy of pre-procedural diagnosis. Although, in these cases magnetic resonance cholangiopancreatography (MRCP) offers a complication-free advantage over diagnostic endoscopic retrograde cholangiopancreatography (ERCP), does not ever clearly distinguish benign from malignant origin strictures. The aim of this observational study is to evaluate the use of a new peroral cholangioscopy system with 10French outer diameter (SpyGlass® Direct Visualization System, Boston Scientific Corporation, Natick, Mass), inserted through the working channel of the interventional duodenoscope, with tissue sample biopsy ability in patients with obstructive jaundice and radiological evidence of indeterminate biliary stricture. Method: Among 632 consecutive ERCP’s (from November 2008 till November 2009), 43 patients with jaundice and MRCP evidence of biliary obstruction were eligible for cholangioscopy with SpyGlass for visual identification and tissue sampling of the stricture. Procedural success rate, defined as the insertion of Spyglass into the common bile duct, visual inspection and tissue biopsy of the biliary stricture, was evaluated. Results: Insertion of the fiberoptic probe into common bile duct and stricture inspection was achieved in all cases (100%). In 3 patients biliary stenosis was due to stones that were kept tightly affixed onto the biliary wall. In 25 patients inspection of stenosis revealed a thickened, hemorrhagic and ulcerated mucosa compatible with carcinoma. Normal mucosa with extrinsic compression was observed in 8 patients, whereas in 7 patients no diagnostic pathology was identified. Tissue biopsy was feasible in 34/40 patients (success rate 85%), with 3 specimens per patient. Targeted tissue biopsies demonstrated positive malignant origin in 22 patients (64.7%) and negative in 9 patients (26.5%), respectively. In 3 cases tissue specimens were pathologically judged as inadequate. Biopsy forceps was impossible to pass through the cholangioscope due to excessive angulation of the catheter at the papilla in 6 patients. No procedure-related complications were noted.Conclusions: SpyGlass cholangioscopy adds a useful diagnostic tool when dealing with radiologically evident biliary strictures. Tissue sampling under visual control is technically feasible and clinically safe. Nevertheless, a short learning curve is required in order adequate optically-directed tissue samples to be provided.
S1473 Comparison of Endoscopic Large-Balloon Sphincteroplasty With Versus Without Preceding Sphincterotomy Wei-Chih Liao, Tsung-Hsien Hsiao, Jaw-Town Lin, Hsiu-Po Wang Background: Endoscopic papillary large-balloon sphincteroplasty (LBS) is increasingly used for large bile duct stones. A preceding endoscopic sphincterotomy (EST) has been considered necessary before LBS to prevent pancreatitis and facilitate stone extraction. A recent study suggested that omission of preceding EST does not increase risk of pancreatitis and may eliminate risk of bleeding. However, its case number was small and involved only patients who underwent LBS without preceding EST.Aim: To compare LBS with versus without preceding EST in terms of risk of pancreatitis, bleeding, and efficacy of stone extraction.Methods: Prospectively maintained ERCP database of a referring center was reviewed. Patients who underwent LBS for bile duct stones between 2007 September to 2009 November were classified into two groups; group 1: LBS without preceding EST, group 2: LBS after failed stone extraction with EST or after prior EST. Primary end points were risk of pancreatitis and bleeding. Secondary end points included efficacy of stone extraction and other complications.Results: 65 patients (group 1, 41; group 2, 24) were identified. Pancreatitis developed in 1 (2.4%) of group 1 and none of group 2. One patient in each group developed bleeding. All complications were successfully managed with medical treatments. No significant differences were
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noted in efficacy of stone extraction between the two groups.Conclusion: Omission of EST before LBS seems not to increase risk of pancreatitis or reduce efficacy of stone extraction. Bleeding can occur even without preceding EST. Without EST (nⴝ41)
With EST (nⴝ24)
Sex, male (%) 22 (53.7) 16 (66.7) Age* 75 (65 - 84) 66.5 (58 - 80) Stone number (one/ 23/18 17/7 multiple) Diameter of largest 12.9 (11.0 - 16.0) 13.0 (10.9 - 15.0) stone (mm)* Duct diameter (mm)* 16.0 (12.5 - 19.0) 15.0 (12.6 - 18.3) Balloon diameter* 18 (15 - 18) 15 (15 - 18) Duct clearance, n (%) With or without ML 37 (90.2) 23 (95.8) Without ML 33 (80.5) 22 (91.7) First session without 31 (75.6) 20 (83.3) ML Complications, n (%) Pancreatitis 1 (2.4) 0 Bleeding 1 (2.4) 1 (4.2) Cholangitis 2 (4.9) 2 (8.3) Perforation 1 (2.4) 0 ML: mechanical lithotripsy. *Expressed as median (interquartile range).
P 0.435 0.042 0.296 0.699 0.822 0.024 0.644 0.301 0.545 1.000 1.000 0.622 1.000
S1474 ERCP in Altered Surgical Gastrointestinal Anatomy: A Single Center Experience Norio Fukami, Brian C. Brauer, Yang K. Chen, Roy D. Yen, Rajasekhara R. Mummadi, Raj J. Shah Background: ERCP in patients with post-surgical anatomy is challenging due to limited access to the papilla or biliary-enteric anastomosis and cannulation. Aim: A retrospective review of ERCP in post-surgical anatomy at a single tertiary referral center. Patients and Methods: The endoscopy database was searched for patients with post-surgical anatomy who underwent ERCP. Patient demographic data, indications, maneuvers, successful access to the target area (ampulla or anastomosis), completion of procedure, and complications were recorded. Results: From 1/2001 to 10/2009, 98 patients with post-surgical anatomy underwent a total of 139 ERCPs performed by four endoscopists. Post surgical anatomy: Billroth II (B-II, N⫽39), Roux-en-Y gastric bypass (RYGB, N⫽18), Roux-en-Y gastrojejunostomy (RYGJ, N⫽7), pancreaticoduodenectomy (PD, N⫽11), and Roux-en-Y hepaticojejunostomy (RYHJ, N⫽23). Procedures were done with duodenoscope or pediatric colonoscope; an conventional overtube or single balloon enteroscopy was used in 4 cases. Rotating overtube enteroscopy assisted ERCP were done in 28 cases. Access to the target orifice was successful in 75 cases (76.5%) and was more frequent in B-II anatomy (90% vs. 68%, p⫽0.012). Cannulation of the desired duct failed in 19 of 115 procedures (16.5%) when the orifice was identified. ERCP was successful at 1st attempt in 60 patients (61.2%), which was lower in non-B-II anatomy (50.8% vs. 76.9% of B-II anatomy, p⫽0.0095). Overall success of ERCP was seen in 68 pts (69.4%) after re-attempts, change in modality (enteroscope assisted ERCP) or laparoscopy assisted procedures for gastric bypass patients. Complications (6%) were all minor, including post procedure abdominal pain (n⫽2), bleeding during the procedure treated endoscopically (n⫽4) and mild pancreatitis (n⫽1). There were no perforations. Conclusions: Post-surgical anatomy poses a significant challenge for ERCP. Although access to the target orifice may improve with a use of enteroscopy assisted-ERCP for patients with non-B-II anatomy, successful cannulation of the desired duct will likely continue to be difficult with a front viewing scope. In our hands, there was no evidence of increased procedural risk of performing ERCP in patients with altered surgical anatomy.
S1475 Endoscopic Variceal Ligation (EVL) Alone Versus Endoscopic Variceal Ligation Plus Propranolol in Variceal Bleeding Prophylaxis in Cirrhotic Patients Danielle Bonilha, Lucianna M. Correia, Gustavo F. Gomes, Juliana D. Brito, Patricia P. Costa, Luciano Lenz, Maria Rachel S. Rohr, Fernanda P. Martins, Frank S. Nakao, Gustavo A. De Paulo, Rodrigo A. Rodrigues, Angelo P. Ferrari, Ermelindo Della Libera Introduction: Bleeding from esophagogastric varices is a major complication of portal hypertension. Beta-blockers are a well-established cornerstone of portal hypertension treatment. Band ligation is the best endoscopic treatment to prevent esophageal variceal bleeding. The exact benefit of beta-blocker association to band ligation remains to be defined. Aims: To compare EVL associated with propranolol versus EVL alone in the prophylaxis of variceal bleeding in cirrhotic patients. Design: Prospective randomized controlled study. Methods: One hundred consecutive patients with high-risk esophageal varices,
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Abstracts with or without prior bleeding, were randomly allocated to EVL alone (Group I, n ⫽ 50) or EVL plus propranolol (Group II, n ⫽ 50). EVL was done every 3 weeks until obliteration. Controls were performed every three months in the first year and then twice a year to check for variceal recurrence. In Group II, propranolol was continued after variceal obliteration until the study end. Measured endpoints were bleeding, death and variceal recurrence. Results: Both groups had comparable baseline characteristics: age, gender, frequency of Child A (33 vs. 32), B (9 vs. 8) or C (9 vs. 9), MELD score (12 ⫾ 3.2 vs. 10.94 ⫾ 2.99), caliber or presence of red wale marks, mean number of sessions and follow-up (9.18 months ⫾ 4.63 vs. 8.76 ⫾ 4.74). 64% of patients in Group I and 68% in Group II were enrolled for primary prophylaxis. Mean propranolol daily dose achieved in Group II was 72 ⫾ 30,23 mg. Seven patients bled before variceal obliteration, 2 in Group I and 5 in Group II (p ⫽ 0.204). Eight patients died, 4 in each Group (p ⫽ 1.000). Deaths were not related to bleeding. Until now, 13 patients in Group I and 4 patients in Group II had variceal recurrence (p ⫽ 0.012). Among patients enrolled for primary prophylaxis, variceal recurrence was lower in the propranolol group (10/32 vs. 2/34 - p ⫽ 0.008). Among patients enrolled for secondary prophylaxis, variceal recurrence was 3/18 vs. 2/16 (p ⫽ 0.851). There were no major complications of EVL. Adverse effects of propranolol were seen in 18% of patients and in 10% it had to be interrupted. Conclusions: EVL alone and EVL plus propranolol were both effective in primary and secondary prophylaxis of bleeding from high-risk esophageal varices in cirrhotic patients. Addition of propranolol did not decreased bleeding until obliteration of varices or mortality in patients on EVL. However, variceal recurrence was lower in the propranolol group.
S1476 Fully Covered Self-Expandable Metal Stent for the Treatment of Benign Esophageal Diseases Johan C. Bakken, Petrus C. De Groen, Louis-Michel Wong Kee Song, Todd H. Baron BACKGROUND: Self-expandable metal stents (SEMS) are not FDA approved for benign esophageal conditions. However, temporary placement of fully covered SEMS (FCSEMS) may be efficacious for such conditions given their low likelihood of tissue embedment. Currently there is only one published US study reporting on FCSEMS for benign diseases. AIM: To report our clinical experience and outcome regarding the use of FCSEMS for benign esophageal diseases. METHODS: The medical records of all patients having undergone FCSEMS placement (Alimaxx-E, Merit Medical Systems, Inc) from 1/1/2005 to 11/11/2009 were reviewed. Fifty-six of 159 patients identified underwent FCSEMS placement for benign esophageal disease. Data were abstracted for patient demographics, indications for stent placement, technical success, clinical outcomes, and stent related complications. RESULTS: Fifty-six (mean age 60 years, 66% male) underwent FCSEMS placement for benign esophageal disease during a total of 107 procedures. Indications for stent placement included benign refractory strictures (N⫽40; 12 reflux or idiopathic, 13 radiation, 15 anastomotic), fistulas (N⫽47), perforations (N⫽18), and esophageal leaks (N⫽2). Stent placement was technically successful in 93% of all attempts. Failure of placement was due to buckling (N⫽3), immediate migration (N⫽2), and stridor (N⫽2). Self-limited post procedural pain and nausea/vomiting after insertion occurred in 12% and 9% of patients, respectively. Three stents were removed within 24 hours due to airway compromise, and emergent tracheostomy was required in one. Clinical success was seen in 56% of patients with refractory strictures, shown by improvement or resolution of dysphagia and/or endoscopic/radiologic evidence of stricture resolution, and seen in 38% of patients with fistula, leak or perforation. Mean duration for stent placement was 65 days for all indications. A rat tooth forceps was most commonly used for stent retrieval, and achieved in all patients without complications. Stent migration occurred when placed proximally and distally in 13/28 (46%) and 19/49 (39%) of procedures, respectively. Migration of midesophageal stents occurred in 6/27 (22%) of procedures. Obstructive granulation tissue was observed in 9 cases at the time of stent removal. In these cases mean duration of stent placement was 100 days. CONCLUSIONS: 1) Temporary placement of fully covered SEMS for benign esophageal conditions has moderate clinical efficacy for treatment of benign esophageal diseases and is limited by stent migration. 2) Removability was easily demonstrated. 3) Newer developments in stent technology may improve clinical outcome for these patients.
esophagus(BE), therefore we need systemic surveillance-biopsies of the remaining BE region. Though we have the option of ablation therapy, we have not reached consensus how the remaining BE should be managed. Aim:To assess the risk of recurrence of dysplasia or cancer in patients who underwent a single endoscopic mucosal resection(EMR) of a neoplastic lesion. Method:This is a retrospective cohort study in a specialty Barrett’s esophagus Unit at a tertiary referral center. Patient demographics and clinical outcome were extracted from a prospectively maintained database. Patients who underwent a single EMR with no histological evidence of dysplasia at the margins of resection were divided into two groups, those that had dysplasia present on surveillance biopsies at the same time of EMR, and those that had no dysplasia. Progression to EAC and high grade dysplasia(HGD) confirmed by follow-up surveillance biopsies in those patients were assessed as primary outcomes. We compared the outcomes between the two groups. Result:279 patients(233 male,mean age 67y/o,mean length of BE 3.5cm,mean followup 31 months) underwent successful EMR for indicated lesions from 1995 to 2009. 131 patients(47%) had dysplasia found on surveillance biopsies at the same time of EMR. 45 of 131 dysplastic patients received additional ablative therapy, whereas 42 of 148 non-dysplastic groups received ablation(p⫽0.30). Overall,4 patients(1.4%) were found to have early EAC by subsequently follow-up biopsies and all of them had had dysplasia at the time of EMR, while none developed EAC in non-dysplastic group(p⫽0.047). Two of these received ablation therapy after initial EMR sessions and others did not. One died but from non-cancer related cause.33 patients progressed to HGD in the remaining Barrett’s mucosa. 22(17%) patients initially had dysplasia and the other 11(7.4%) patients developed from formally non-dysplastic lesions (p⫽0.025).In dysplasia group,there was no statistical difference between those that received ablation and those that did not in progression (p⫽0.62). Conclusion:This is the first report of the outcome of remaining Barrett’s mucosa in patients who underwent successful EMR of focal lesions in BE from a high volume specialized unit. Our study showed patients with residual dysplasia in Barrett’s mucosa progressed to EAC and HGD with significantly higher prevalence than those without dysplasia. Although a few patients without dysplasia progressed to HGD after resection, it appears that ablation in this group might be individualized.
S1478 The Clinical Significance of Minimal Changes in Gastroesophageal Reflux Disease Based on GerdQ: A Prospective, Multicenter Study - Might Study Group Jie-Hyun Kim, Hyojin Park Background/Aims: Endoscopy is the gold standard for the diagnosis of erosive gastroesophageal reflux disease (GERD). Although minimal changes are known as one of the endoscopic findings of non-erosive reflux disease (NERD), the clinical significance of minimal changes is controversy. The aim of study is to evaluate the clinical significance of minimal changes by investigating the endoscopic findings of minimal changes to have diagnostic value for GERD. Methods: From April to September 2009, the endoscopic findings of 1,445 patients were defined as minimal changes in 30 institutions. The endoscopic criteria for assessing minimal changes were divided into six findings, reported acceptable to good agreement between endoscopists such as erythema, blurring of Z-line, friability, decreased vascularity, white turbid discoloration, edema and/ or accentuation of mucosal folds.1 The diagnosis of GERD was based on GerdQ, valuable questionnaire to identity GERD among patients with upper gastrointestinal symptoms.2 Results: 643 (44.5%) among 1,445 patients were categorized as GERD-group based on GerdQ. There were no significant differences of clinical characteristics between GERD- and non-GERD groups except age and height. Blurring of Z-line (50.4%) and erythema (45.7%) were the most common endoscopic findings for minimal changes in this study. However, just one (16.7%, edema and/or fold accentuation) of six findings was significantly common in GERD-group compared with non-GERD group (16.0% vs. 11.5%, P⫽0.01). More than one of endoscopic findings was not more useful to identify GERD than one of endoscopic findings (44.3% vs. 44.7%, P⬎0.05). Conclusions: The large portion of endoscopic findings for minimal changes may not be associated with GERD. The clinical significance of minimal changes in GERD should be reconsidered. References1. Armstrong D, Bennee JR, Blum AL, et al. The endoscopic assessment of esophagitis: A progress report on observer agreement. Gastroenterology 1996;111:85-92.2. Jones R, Junghard O, Dent J, et al. Development of the GerdQ, a tool for the diagnosis and management of gastro-esophageal reflux disease in primary care. Aliment Pharmacol Therap 2009.
S1477 Should We Still Ablate the Residual Barrett’s Mucosa After Successful EMR of a Neoplastic Lesion in Barrett’s Esophagus Yutaka Tomizawa, Ganapathy A. Prasad, Louis-Michel Wong Kee Song, Navtej Buttar, Ngozi I. Okoro, Vikneswaran Namasivayam, Marlys Anderson, Kelly T. Dunagan, Lynn S. Borkenhagen, Lori S. Lutzke, Kenneth K. Wang
S1479 Are There Factors That Predict Which Patients Undergoing Radiofrequency Ablation of Barrett’s Esophagus Will Require Prolonged Ablation Therapy? Susumu Shinoura, Kenneth J. Chang, Takuji Iwashita, John G. Lee, V. Raman Muthusamy
Background:Accumulative evidence has shown patchy, irregular distribution of dysplasia and early esophageal adenocarcinoma(EAC) in Barrett’s
BACKGROUND & AIMS: Radiofrequency ablation (RFA) is safe and effective for eradicating intestinal metaplasia (IM) in patients with Barrett’s esophagus (BE)
AB172 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
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S1472 SpyGlass® Peroral Cholangioscopy System for Visual Differentiation and Optically Guided Tissue Sample Biopsy of Biliary Strictures: A Single-Center Preliminary Observational Study Dimitrios Xinopoulos, Stefanos P. Bassioukas, Dimitrios Kypreos, Dimitrios Dimitroulopoulos, Dimitris P. Korkolis, Klisthenis Tsamakidis, Argyro Loukou, Apostolos Poulakis, Emmanuil Paraskevas Introduction: Appropriate endoscopic or and surgical treatment of biliary strictures mainly depends on the accuracy of pre-procedural diagnosis. Although, in these cases magnetic resonance cholangiopancreatography (MRCP) offers a complication-free advantage over diagnostic endoscopic retrograde cholangiopancreatography (ERCP), does not ever clearly distinguish benign from malignant origin strictures. The aim of this observational study is to evaluate the use of a new peroral cholangioscopy system with 10French outer diameter (SpyGlass® Direct Visualization System, Boston Scientific Corporation, Natick, Mass), inserted through the working channel of the interventional duodenoscope, with tissue sample biopsy ability in patients with obstructive jaundice and radiological evidence of indeterminate biliary stricture. Method: Among 632 consecutive ERCP’s (from November 2008 till November 2009), 43 patients with jaundice and MRCP evidence of biliary obstruction were eligible for cholangioscopy with SpyGlass for visual identification and tissue sampling of the stricture. Procedural success rate, defined as the insertion of Spyglass into the common bile duct, visual inspection and tissue biopsy of the biliary stricture, was evaluated. Results: Insertion of the fiberoptic probe into common bile duct and stricture inspection was achieved in all cases (100%). In 3 patients biliary stenosis was due to stones that were kept tightly affixed onto the biliary wall. In 25 patients inspection of stenosis revealed a thickened, hemorrhagic and ulcerated mucosa compatible with carcinoma. Normal mucosa with extrinsic compression was observed in 8 patients, whereas in 7 patients no diagnostic pathology was identified. Tissue biopsy was feasible in 34/40 patients (success rate 85%), with 3 specimens per patient. Targeted tissue biopsies demonstrated positive malignant origin in 22 patients (64.7%) and negative in 9 patients (26.5%), respectively. In 3 cases tissue specimens were pathologically judged as inadequate. Biopsy forceps was impossible to pass through the cholangioscope due to excessive angulation of the catheter at the papilla in 6 patients. No procedure-related complications were noted.Conclusions: SpyGlass cholangioscopy adds a useful diagnostic tool when dealing with radiologically evident biliary strictures. Tissue sampling under visual control is technically feasible and clinically safe. Nevertheless, a short learning curve is required in order adequate optically-directed tissue samples to be provided.
S1473 Comparison of Endoscopic Large-Balloon Sphincteroplasty With Versus Without Preceding Sphincterotomy Wei-Chih Liao, Tsung-Hsien Hsiao, Jaw-Town Lin, Hsiu-Po Wang Background: Endoscopic papillary large-balloon sphincteroplasty (LBS) is increasingly used for large bile duct stones. A preceding endoscopic sphincterotomy (EST) has been considered necessary before LBS to prevent pancreatitis and facilitate stone extraction. A recent study suggested that omission of preceding EST does not increase risk of pancreatitis and may eliminate risk of bleeding. However, its case number was small and involved only patients who underwent LBS without preceding EST.Aim: To compare LBS with versus without preceding EST in terms of risk of pancreatitis, bleeding, and efficacy of stone extraction.Methods: Prospectively maintained ERCP database of a referring center was reviewed. Patients who underwent LBS for bile duct stones between 2007 September to 2009 November were classified into two groups; group 1: LBS without preceding EST, group 2: LBS after failed stone extraction with EST or after prior EST. Primary end points were risk of pancreatitis and bleeding. Secondary end points included efficacy of stone extraction and other complications.Results: 65 patients (group 1, 41; group 2, 24) were identified. Pancreatitis developed in 1 (2.4%) of group 1 and none of group 2. One patient in each group developed bleeding. All complications were successfully managed with medical treatments. No significant differences were
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noted in efficacy of stone extraction between the two groups.Conclusion: Omission of EST before LBS seems not to increase risk of pancreatitis or reduce efficacy of stone extraction. Bleeding can occur even without preceding EST. Without EST (nⴝ41)
With EST (nⴝ24)
Sex, male (%) 22 (53.7) 16 (66.7) Age* 75 (65 - 84) 66.5 (58 - 80) Stone number (one/ 23/18 17/7 multiple) Diameter of largest 12.9 (11.0 - 16.0) 13.0 (10.9 - 15.0) stone (mm)* Duct diameter (mm)* 16.0 (12.5 - 19.0) 15.0 (12.6 - 18.3) Balloon diameter* 18 (15 - 18) 15 (15 - 18) Duct clearance, n (%) With or without ML 37 (90.2) 23 (95.8) Without ML 33 (80.5) 22 (91.7) First session without 31 (75.6) 20 (83.3) ML Complications, n (%) Pancreatitis 1 (2.4) 0 Bleeding 1 (2.4) 1 (4.2) Cholangitis 2 (4.9) 2 (8.3) Perforation 1 (2.4) 0 ML: mechanical lithotripsy. *Expressed as median (interquartile range).
P 0.435 0.042 0.296 0.699 0.822 0.024 0.644 0.301 0.545 1.000 1.000 0.622 1.000
S1474 ERCP in Altered Surgical Gastrointestinal Anatomy: A Single Center Experience Norio Fukami, Brian C. Brauer, Yang K. Chen, Roy D. Yen, Rajasekhara R. Mummadi, Raj J. Shah Background: ERCP in patients with post-surgical anatomy is challenging due to limited access to the papilla or biliary-enteric anastomosis and cannulation. Aim: A retrospective review of ERCP in post-surgical anatomy at a single tertiary referral center. Patients and Methods: The endoscopy database was searched for patients with post-surgical anatomy who underwent ERCP. Patient demographic data, indications, maneuvers, successful access to the target area (ampulla or anastomosis), completion of procedure, and complications were recorded. Results: From 1/2001 to 10/2009, 98 patients with post-surgical anatomy underwent a total of 139 ERCPs performed by four endoscopists. Post surgical anatomy: Billroth II (B-II, N⫽39), Roux-en-Y gastric bypass (RYGB, N⫽18), Roux-en-Y gastrojejunostomy (RYGJ, N⫽7), pancreaticoduodenectomy (PD, N⫽11), and Roux-en-Y hepaticojejunostomy (RYHJ, N⫽23). Procedures were done with duodenoscope or pediatric colonoscope; an conventional overtube or single balloon enteroscopy was used in 4 cases. Rotating overtube enteroscopy assisted ERCP were done in 28 cases. Access to the target orifice was successful in 75 cases (76.5%) and was more frequent in B-II anatomy (90% vs. 68%, p⫽0.012). Cannulation of the desired duct failed in 19 of 115 procedures (16.5%) when the orifice was identified. ERCP was successful at 1st attempt in 60 patients (61.2%), which was lower in non-B-II anatomy (50.8% vs. 76.9% of B-II anatomy, p⫽0.0095). Overall success of ERCP was seen in 68 pts (69.4%) after re-attempts, change in modality (enteroscope assisted ERCP) or laparoscopy assisted procedures for gastric bypass patients. Complications (6%) were all minor, including post procedure abdominal pain (n⫽2), bleeding during the procedure treated endoscopically (n⫽4) and mild pancreatitis (n⫽1). There were no perforations. Conclusions: Post-surgical anatomy poses a significant challenge for ERCP. Although access to the target orifice may improve with a use of enteroscopy assisted-ERCP for patients with non-B-II anatomy, successful cannulation of the desired duct will likely continue to be difficult with a front viewing scope. In our hands, there was no evidence of increased procedural risk of performing ERCP in patients with altered surgical anatomy.
S1475 Endoscopic Variceal Ligation (EVL) Alone Versus Endoscopic Variceal Ligation Plus Propranolol in Variceal Bleeding Prophylaxis in Cirrhotic Patients Danielle Bonilha, Lucianna M. Correia, Gustavo F. Gomes, Juliana D. Brito, Patricia P. Costa, Luciano Lenz, Maria Rachel S. Rohr, Fernanda P. Martins, Frank S. Nakao, Gustavo A. De Paulo, Rodrigo A. Rodrigues, Angelo P. Ferrari, Ermelindo Della Libera Introduction: Bleeding from esophagogastric varices is a major complication of portal hypertension. Beta-blockers are a well-established cornerstone of portal hypertension treatment. Band ligation is the best endoscopic treatment to prevent esophageal variceal bleeding. The exact benefit of beta-blocker association to band ligation remains to be defined. Aims: To compare EVL associated with propranolol versus EVL alone in the prophylaxis of variceal bleeding in cirrhotic patients. Design: Prospective randomized controlled study. Methods: One hundred consecutive patients with high-risk esophageal varices,
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Abstracts with or without prior bleeding, were randomly allocated to EVL alone (Group I, n ⫽ 50) or EVL plus propranolol (Group II, n ⫽ 50). EVL was done every 3 weeks until obliteration. Controls were performed every three months in the first year and then twice a year to check for variceal recurrence. In Group II, propranolol was continued after variceal obliteration until the study end. Measured endpoints were bleeding, death and variceal recurrence. Results: Both groups had comparable baseline characteristics: age, gender, frequency of Child A (33 vs. 32), B (9 vs. 8) or C (9 vs. 9), MELD score (12 ⫾ 3.2 vs. 10.94 ⫾ 2.99), caliber or presence of red wale marks, mean number of sessions and follow-up (9.18 months ⫾ 4.63 vs. 8.76 ⫾ 4.74). 64% of patients in Group I and 68% in Group II were enrolled for primary prophylaxis. Mean propranolol daily dose achieved in Group II was 72 ⫾ 30,23 mg. Seven patients bled before variceal obliteration, 2 in Group I and 5 in Group II (p ⫽ 0.204). Eight patients died, 4 in each Group (p ⫽ 1.000). Deaths were not related to bleeding. Until now, 13 patients in Group I and 4 patients in Group II had variceal recurrence (p ⫽ 0.012). Among patients enrolled for primary prophylaxis, variceal recurrence was lower in the propranolol group (10/32 vs. 2/34 - p ⫽ 0.008). Among patients enrolled for secondary prophylaxis, variceal recurrence was 3/18 vs. 2/16 (p ⫽ 0.851). There were no major complications of EVL. Adverse effects of propranolol were seen in 18% of patients and in 10% it had to be interrupted. Conclusions: EVL alone and EVL plus propranolol were both effective in primary and secondary prophylaxis of bleeding from high-risk esophageal varices in cirrhotic patients. Addition of propranolol did not decreased bleeding until obliteration of varices or mortality in patients on EVL. However, variceal recurrence was lower in the propranolol group.
S1476 Fully Covered Self-Expandable Metal Stent for the Treatment of Benign Esophageal Diseases Johan C. Bakken, Petrus C. De Groen, Louis-Michel Wong Kee Song, Todd H. Baron BACKGROUND: Self-expandable metal stents (SEMS) are not FDA approved for benign esophageal conditions. However, temporary placement of fully covered SEMS (FCSEMS) may be efficacious for such conditions given their low likelihood of tissue embedment. Currently there is only one published US study reporting on FCSEMS for benign diseases. AIM: To report our clinical experience and outcome regarding the use of FCSEMS for benign esophageal diseases. METHODS: The medical records of all patients having undergone FCSEMS placement (Alimaxx-E, Merit Medical Systems, Inc) from 1/1/2005 to 11/11/2009 were reviewed. Fifty-six of 159 patients identified underwent FCSEMS placement for benign esophageal disease. Data were abstracted for patient demographics, indications for stent placement, technical success, clinical outcomes, and stent related complications. RESULTS: Fifty-six (mean age 60 years, 66% male) underwent FCSEMS placement for benign esophageal disease during a total of 107 procedures. Indications for stent placement included benign refractory strictures (N⫽40; 12 reflux or idiopathic, 13 radiation, 15 anastomotic), fistulas (N⫽47), perforations (N⫽18), and esophageal leaks (N⫽2). Stent placement was technically successful in 93% of all attempts. Failure of placement was due to buckling (N⫽3), immediate migration (N⫽2), and stridor (N⫽2). Self-limited post procedural pain and nausea/vomiting after insertion occurred in 12% and 9% of patients, respectively. Three stents were removed within 24 hours due to airway compromise, and emergent tracheostomy was required in one. Clinical success was seen in 56% of patients with refractory strictures, shown by improvement or resolution of dysphagia and/or endoscopic/radiologic evidence of stricture resolution, and seen in 38% of patients with fistula, leak or perforation. Mean duration for stent placement was 65 days for all indications. A rat tooth forceps was most commonly used for stent retrieval, and achieved in all patients without complications. Stent migration occurred when placed proximally and distally in 13/28 (46%) and 19/49 (39%) of procedures, respectively. Migration of midesophageal stents occurred in 6/27 (22%) of procedures. Obstructive granulation tissue was observed in 9 cases at the time of stent removal. In these cases mean duration of stent placement was 100 days. CONCLUSIONS: 1) Temporary placement of fully covered SEMS for benign esophageal conditions has moderate clinical efficacy for treatment of benign esophageal diseases and is limited by stent migration. 2) Removability was easily demonstrated. 3) Newer developments in stent technology may improve clinical outcome for these patients.
esophagus(BE), therefore we need systemic surveillance-biopsies of the remaining BE region. Though we have the option of ablation therapy, we have not reached consensus how the remaining BE should be managed. Aim:To assess the risk of recurrence of dysplasia or cancer in patients who underwent a single endoscopic mucosal resection(EMR) of a neoplastic lesion. Method:This is a retrospective cohort study in a specialty Barrett’s esophagus Unit at a tertiary referral center. Patient demographics and clinical outcome were extracted from a prospectively maintained database. Patients who underwent a single EMR with no histological evidence of dysplasia at the margins of resection were divided into two groups, those that had dysplasia present on surveillance biopsies at the same time of EMR, and those that had no dysplasia. Progression to EAC and high grade dysplasia(HGD) confirmed by follow-up surveillance biopsies in those patients were assessed as primary outcomes. We compared the outcomes between the two groups. Result:279 patients(233 male,mean age 67y/o,mean length of BE 3.5cm,mean followup 31 months) underwent successful EMR for indicated lesions from 1995 to 2009. 131 patients(47%) had dysplasia found on surveillance biopsies at the same time of EMR. 45 of 131 dysplastic patients received additional ablative therapy, whereas 42 of 148 non-dysplastic groups received ablation(p⫽0.30). Overall,4 patients(1.4%) were found to have early EAC by subsequently follow-up biopsies and all of them had had dysplasia at the time of EMR, while none developed EAC in non-dysplastic group(p⫽0.047). Two of these received ablation therapy after initial EMR sessions and others did not. One died but from non-cancer related cause.33 patients progressed to HGD in the remaining Barrett’s mucosa. 22(17%) patients initially had dysplasia and the other 11(7.4%) patients developed from formally non-dysplastic lesions (p⫽0.025).In dysplasia group,there was no statistical difference between those that received ablation and those that did not in progression (p⫽0.62). Conclusion:This is the first report of the outcome of remaining Barrett’s mucosa in patients who underwent successful EMR of focal lesions in BE from a high volume specialized unit. Our study showed patients with residual dysplasia in Barrett’s mucosa progressed to EAC and HGD with significantly higher prevalence than those without dysplasia. Although a few patients without dysplasia progressed to HGD after resection, it appears that ablation in this group might be individualized.
S1478 The Clinical Significance of Minimal Changes in Gastroesophageal Reflux Disease Based on GerdQ: A Prospective, Multicenter Study - Might Study Group Jie-Hyun Kim, Hyojin Park Background/Aims: Endoscopy is the gold standard for the diagnosis of erosive gastroesophageal reflux disease (GERD). Although minimal changes are known as one of the endoscopic findings of non-erosive reflux disease (NERD), the clinical significance of minimal changes is controversy. The aim of study is to evaluate the clinical significance of minimal changes by investigating the endoscopic findings of minimal changes to have diagnostic value for GERD. Methods: From April to September 2009, the endoscopic findings of 1,445 patients were defined as minimal changes in 30 institutions. The endoscopic criteria for assessing minimal changes were divided into six findings, reported acceptable to good agreement between endoscopists such as erythema, blurring of Z-line, friability, decreased vascularity, white turbid discoloration, edema and/ or accentuation of mucosal folds.1 The diagnosis of GERD was based on GerdQ, valuable questionnaire to identity GERD among patients with upper gastrointestinal symptoms.2 Results: 643 (44.5%) among 1,445 patients were categorized as GERD-group based on GerdQ. There were no significant differences of clinical characteristics between GERD- and non-GERD groups except age and height. Blurring of Z-line (50.4%) and erythema (45.7%) were the most common endoscopic findings for minimal changes in this study. However, just one (16.7%, edema and/or fold accentuation) of six findings was significantly common in GERD-group compared with non-GERD group (16.0% vs. 11.5%, P⫽0.01). More than one of endoscopic findings was not more useful to identify GERD than one of endoscopic findings (44.3% vs. 44.7%, P⬎0.05). Conclusions: The large portion of endoscopic findings for minimal changes may not be associated with GERD. The clinical significance of minimal changes in GERD should be reconsidered. References1. Armstrong D, Bennee JR, Blum AL, et al. The endoscopic assessment of esophagitis: A progress report on observer agreement. Gastroenterology 1996;111:85-92.2. Jones R, Junghard O, Dent J, et al. Development of the GerdQ, a tool for the diagnosis and management of gastro-esophageal reflux disease in primary care. Aliment Pharmacol Therap 2009.
S1477 Should We Still Ablate the Residual Barrett’s Mucosa After Successful EMR of a Neoplastic Lesion in Barrett’s Esophagus Yutaka Tomizawa, Ganapathy A. Prasad, Louis-Michel Wong Kee Song, Navtej Buttar, Ngozi I. Okoro, Vikneswaran Namasivayam, Marlys Anderson, Kelly T. Dunagan, Lynn S. Borkenhagen, Lori S. Lutzke, Kenneth K. Wang
S1479 Are There Factors That Predict Which Patients Undergoing Radiofrequency Ablation of Barrett’s Esophagus Will Require Prolonged Ablation Therapy? Susumu Shinoura, Kenneth J. Chang, Takuji Iwashita, John G. Lee, V. Raman Muthusamy
Background:Accumulative evidence has shown patchy, irregular distribution of dysplasia and early esophageal adenocarcinoma(EAC) in Barrett’s
BACKGROUND & AIMS: Radiofrequency ablation (RFA) is safe and effective for eradicating intestinal metaplasia (IM) in patients with Barrett’s esophagus (BE)
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