- Email: [email protected]
S1493: Endoscopic Radiofrequency Ablation for HGD or IMC in Barrett's Esophagus - Results From the First 100 Patients Enrolled in the UK RFA Registry
Abstracts (HH) were noted. Uni-variate analyses were performed to compare the two groups: CLE only and CLE with documented IM. Results: A total of 974 patients with GERD symptoms were enrolled. On index endoscopy, the prevalence of CLE with IM was 13% (n⫽141) whereas that of any CLE was 24% (233/974). The average length was shorter in those with any CLE compared to those with CLE with IM [(1.24 vs. 2.85 cm), p⬍0.001]. Mean age (59yrs), and BMI (29) were comparable between the groups, however number of Caucasians (85% vs. 94%), (p ⬍0.05), HH frequency (50% vs. 73%), (p ⬍0.001) and mean size (2.5 vs. 3.1), (p⬍0.005) and severe GERD (27% vs. 42%), (p ⬍0.05) were significantly lower in the all CLE group. Conclusion: Defining BE by the presence of CLE alone significantly increased the prevalence of BE on index endoscopy to include up to 25% of the patients in this large prospective cohort study of GERD patients. This has significant implications for burden of BE, potentially doubling the number of BE patients that will need to be considered for surveillance. This major impact (i.e. diagnosing 1 in 4-5 GERD patients with BE) should be borne in mind as the definition of BE is formulated.
S1491 Acetic Acid Enhanced Chromoendoscopy in the Detection of Dysplasia Within Barrett’s Oesophagus: A Prospective Series Gaius R. Longcroft-Wheaton, Robert J. Mead, Moses Duku, David Poller, Pradeep Bhandari INTRODUCTION: The current accepted standard of care in Barrett’s surveillance has involved the routine collection of large numbers of non-targeted biopsies (Seattle protocol). This is time consuming, expensive and can miss significant abnormalities. Acetic acid has been demonstrated to be effective in identifying areas of metaplasia, with an increasing number of endoscopists questioning whether it has a role in the identification of dysplasia. We aim to evaluate the use of acetic acid (AA) chromoendocopy in the assessment of Barrett’s neoplasia.METHODS: We prospectively collected data on patients with Barrett’s oesophagus who had undergone Chromoendoscopy between July 2004 and November 2009. All procedures were performed by a single experienced endoscopist (PB) using fujinon (EG-590) gastroscopes and EPX 4400 processor. The mucosae was examined with white light (WLI) high resolution endoscopy (HRE) and visible abnormalities recorded. Acetic acid (2.5%) dye spray was then performed, and all additional visible abnormalities were characterized and targeted biopsies taken. Quadrantic biopsies at 2 cm intervals of the remaining Barretts epithelium were then taken in all patients. The chromoendoscopic diagnosis was compared with the histological diagnosis to evaluate the sensitivity and specificity of AA chromoendoscopy.RESULTS: We performed a total of 335 procedures on 173 patients. The mean age of the group was 67 yrs with 75% males. The prevalence of dysplasia or malignancy in this cohort was 46%. The mean length of Barrett’s oesophagus was 3.7 cm (range 2-15) Pearson’s rank correlation showed a statistically significant correlation between the chromoendoscopic targeted histology and the actual histology (qudrantic ⫹ targeted histology) (r ⫽ 0.9). We applied the Chi2 test to our data and found a significant difference between visible neoplasia seen on WLI vs AA chromoendoscopy. (p⬍0.001) See table 1. The sensitivity was 93% with a specificity of 80% for all neoplasia. CONCLUSIONS: This is the largest world series of acetic acid (AA) chromoendoscopic evaluation of Barrett’s oesophagus. It demonstrates that dye spray improves the neoplasia detection rate by 2.4 fold, with an excellent correlation with the overall diagnosis. this questions the validity of current surveillance strategy of multiple random biopsies. Table 1
Normal Dysplasia Cancer
Histology (A)
WLI (B)
Chromoendoscopy (C)
Change in diagnosis (C/B)
181 113 41
258 61 16
153 148 34
0.6 fold 2.5 fold P⬍0.001
S1492 Endoscopic Treatment of Zenker’s Diverticulum: Comparison of Two Techniques Martin Bortlik, Milan Lukas Background: Zenker’s diverticulum (ZD) affects usually elderly patients and minimally invasive therapy is therefore of great benefit. During past two decades different techniques using flexible endoscope (gastroscope) were developed. Technically, they all consist of cricopharyngeal myotomy and division of the septum between the diverticulum and esophagus. The aim of our study was to compare two easily available techniques: 1. The APC septotomy with placement of naso-gastric tube, and 2. The needle knife septotomy using the flexible diverticuloscope.Methods: In total, 34 ZD patients were treated endoscopically at our center between September 1998 and October 2009. Eighteen patients (10 females, median age 75 years, range 53-86) treated between 1998 and 2003 underwent an APC septotomy after the naso-gastric tube was placed in order to
AB176 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
improve the exposure of the septum (Group 1). Subsequent group of 16 patients (from 2004 onwards, 8 females, median age 69, range 58-83) was treated using the flexible diverticuloscope with two soft flaps at the distal end allowing a better fixation of the septum (Group 2). This plastic tube also protects both esophageal wall as well as airways from injury and aspiration. The primary objective was to compare the number of sessions needed to achieve satisfactory clinical improvement. The number of complications was also assessed and compared during median follow-up (FU) of 11 months (range 1-35)Results: The median number of sessions until the patient has reported substantial improvement was 4 (range 1-7) in Group 1, and 1 (range 1-2) in Group 2, respectively (p ⬍ 0,05). The later technique was judged by both endoscopists as substantially easier and probably safer as compared with the former technique. The most critical point for successful therapy was fixation and good exposure of the septum; both aspects were feasible almost ideally with the diverticuloscope. The procedure was also quicker and resulted in less pain during subsequent hours and days. There was no major complication in our patients; the minor problems, however, were more likely among patients from the Group 1 (hoarseness, pain, subfebrility). No patient died during the follow-up time.Conclusion: Endoscopic therapy of Zenker’s diverticulum using the plastic diverticuloscope yielded better results when compared with older technique based on the naso-gastric tube placement and subsequent APC myotomy.
S1493 Endoscopic Radiofrequency Ablation for HGD or IMC in Barrett’s Esophagus - Results From the First 100 Patients Enrolled in the UK RFA Registry Jason M. Dunn, Sally Thorpe, Grant M. Fullarton, Howard Smart, Ian D. Penman, Praful Patel, Robert P. Willert, Marco Novelli, Matthew R. Banks, Laurence Lovat Background The incidences of Barrett’s esophagus (BE) and associated oesophageal adenocarcinoma are increasing rapidly in the UK. Radiofrequency ablation (RFA) with a circumferential balloon based device (CA) and endoscopemounted focal ablation device (FA) are promising modalities for treating dysplasia arising in BE. Aim To determine the safety and efficacy of RFA for treating dysplastic BE in a UK patient cohort.Study design Multicenter UK registry. Seven teaching and private hospitals; treatment period from April 2007 to November 2009.Methods Patients with histological evidence of dysplasia or intramucosal cancer (IMC) arising in BE confirmed by 2 specialist GI pathologists. A prior EMR was permitted, provided that residual dysplasia remained in the BE region for ablation. RFA was performed every 3 months with follow-up biopsy upon achieving either complete endoscopic eradication of BE or after 4 consecutive ablations. The primary endpoint was complete response for high grade dysplasia (CR-HGD), dysplasia (CR-D) and intestinal metaplasia (CR-IM), defined as no biopsy showing each respective finding.Results A total of 106 patients (79% male, median age 69 years, interquartile range {IQR} 50-83 years) have been treated so far. Accrual rates now exceed 15 patients per quarter. 83 had HGD, 22 IMC, 1 LGD. Median length of BE was 6cm (IQR 115cm). 54% had prior EMR, 25% had previous PDT or APC. 42 patients have completed treatment with at least 1 follow-up biopsy session (median follow-up 4 months, IQR 2-24). Median number of treatments is 1 CA (IQR 0-3) and 1 FA (IQR 0-3). CR-HGD was achieved in 90% of patients, CR-D in 79% and CR-IM in 33%. There were 8 new strictures, 3 mucosal injuries during RFA (1.5%) and 1 perforation (patient previously treated with PDT) (0.5%).Conclusion Reversal of IM is currently poor, but many of these patients have had multiple previous ablative therapies and may represent a particularly difficult group to treat. Despite this, radiofrequency ablation safely achieved a CR-HGD in 90% of patients treated within a UK multicenter registry. These data are similar to other registries.
S1494 Fully Covered, Retrievable Self-Expanding Metal Stents (Niti-S) in Palliation of Malignant Dysphagia Long-Term Results of a Prospective Study (10 Years) Jin Hong Kim, Sung Jun Choi, Jeong Woo Choi, Sung Jae Shin, Kee Myung Lee, Kwang Jae Lee, Sun Gyo Lim Background: The covered self expanding metal stent (SEMS) has become the main treatment option of malignant esophageal obstruction. However, the fully covered SEMS has not been as popular as the partially covered one for the fear of migration in spite of much advantage. So, we performed a prospective study to evaluate clinical efficacy of the fully covered SEMS. Methods: Between October 1998 and February 2009, 100 consecutive patients with malignant esophageal obstruction who were treated with the fully covered Niti-S stent (NitiS, Taewoong Medical, Seoul, Korea) were included. Data collected contained technical success rate of deployment and retrieval, dysphagia score changes, success rate of esophagorespiratory fistula (ERF) resolution, survival, stent patency and complications. We also conducted analyses concerning the associations between results and variables. Result: Technical success rate of stent
www.giejournal.org
S1491 Acetic Acid Enhanced Chromoendoscopy in the Detection of Dysplasia Within Barrett’s Oesophagus: A Prospective Series Gaius R. Longcroft-Wheaton, Robert J. Mead, Moses Duku, David Poller, Pradeep Bhandari INTRODUCTION: The current accepted standard of care in Barrett’s surveillance has involved the routine collection of large numbers of non-targeted biopsies (Seattle protocol). This is time consuming, expensive and can miss significant abnormalities. Acetic acid has been demonstrated to be effective in identifying areas of metaplasia, with an increasing number of endoscopists questioning whether it has a role in the identification of dysplasia. We aim to evaluate the use of acetic acid (AA) chromoendocopy in the assessment of Barrett’s neoplasia.METHODS: We prospectively collected data on patients with Barrett’s oesophagus who had undergone Chromoendoscopy between July 2004 and November 2009. All procedures were performed by a single experienced endoscopist (PB) using fujinon (EG-590) gastroscopes and EPX 4400 processor. The mucosae was examined with white light (WLI) high resolution endoscopy (HRE) and visible abnormalities recorded. Acetic acid (2.5%) dye spray was then performed, and all additional visible abnormalities were characterized and targeted biopsies taken. Quadrantic biopsies at 2 cm intervals of the remaining Barretts epithelium were then taken in all patients. The chromoendoscopic diagnosis was compared with the histological diagnosis to evaluate the sensitivity and specificity of AA chromoendoscopy.RESULTS: We performed a total of 335 procedures on 173 patients. The mean age of the group was 67 yrs with 75% males. The prevalence of dysplasia or malignancy in this cohort was 46%. The mean length of Barrett’s oesophagus was 3.7 cm (range 2-15) Pearson’s rank correlation showed a statistically significant correlation between the chromoendoscopic targeted histology and the actual histology (qudrantic ⫹ targeted histology) (r ⫽ 0.9). We applied the Chi2 test to our data and found a significant difference between visible neoplasia seen on WLI vs AA chromoendoscopy. (p⬍0.001) See table 1. The sensitivity was 93% with a specificity of 80% for all neoplasia. CONCLUSIONS: This is the largest world series of acetic acid (AA) chromoendoscopic evaluation of Barrett’s oesophagus. It demonstrates that dye spray improves the neoplasia detection rate by 2.4 fold, with an excellent correlation with the overall diagnosis. this questions the validity of current surveillance strategy of multiple random biopsies. Table 1
Normal Dysplasia Cancer
Histology (A)
WLI (B)
Chromoendoscopy (C)
Change in diagnosis (C/B)
181 113 41
258 61 16
153 148 34
0.6 fold 2.5 fold P⬍0.001
S1492 Endoscopic Treatment of Zenker’s Diverticulum: Comparison of Two Techniques Martin Bortlik, Milan Lukas Background: Zenker’s diverticulum (ZD) affects usually elderly patients and minimally invasive therapy is therefore of great benefit. During past two decades different techniques using flexible endoscope (gastroscope) were developed. Technically, they all consist of cricopharyngeal myotomy and division of the septum between the diverticulum and esophagus. The aim of our study was to compare two easily available techniques: 1. The APC septotomy with placement of naso-gastric tube, and 2. The needle knife septotomy using the flexible diverticuloscope.Methods: In total, 34 ZD patients were treated endoscopically at our center between September 1998 and October 2009. Eighteen patients (10 females, median age 75 years, range 53-86) treated between 1998 and 2003 underwent an APC septotomy after the naso-gastric tube was placed in order to
AB176 GASTROINTESTINAL ENDOSCOPY
Volume 71, No. 5 : 2010
improve the exposure of the septum (Group 1). Subsequent group of 16 patients (from 2004 onwards, 8 females, median age 69, range 58-83) was treated using the flexible diverticuloscope with two soft flaps at the distal end allowing a better fixation of the septum (Group 2). This plastic tube also protects both esophageal wall as well as airways from injury and aspiration. The primary objective was to compare the number of sessions needed to achieve satisfactory clinical improvement. The number of complications was also assessed and compared during median follow-up (FU) of 11 months (range 1-35)Results: The median number of sessions until the patient has reported substantial improvement was 4 (range 1-7) in Group 1, and 1 (range 1-2) in Group 2, respectively (p ⬍ 0,05). The later technique was judged by both endoscopists as substantially easier and probably safer as compared with the former technique. The most critical point for successful therapy was fixation and good exposure of the septum; both aspects were feasible almost ideally with the diverticuloscope. The procedure was also quicker and resulted in less pain during subsequent hours and days. There was no major complication in our patients; the minor problems, however, were more likely among patients from the Group 1 (hoarseness, pain, subfebrility). No patient died during the follow-up time.Conclusion: Endoscopic therapy of Zenker’s diverticulum using the plastic diverticuloscope yielded better results when compared with older technique based on the naso-gastric tube placement and subsequent APC myotomy.
S1493 Endoscopic Radiofrequency Ablation for HGD or IMC in Barrett’s Esophagus - Results From the First 100 Patients Enrolled in the UK RFA Registry Jason M. Dunn, Sally Thorpe, Grant M. Fullarton, Howard Smart, Ian D. Penman, Praful Patel, Robert P. Willert, Marco Novelli, Matthew R. Banks, Laurence Lovat Background The incidences of Barrett’s esophagus (BE) and associated oesophageal adenocarcinoma are increasing rapidly in the UK. Radiofrequency ablation (RFA) with a circumferential balloon based device (CA) and endoscopemounted focal ablation device (FA) are promising modalities for treating dysplasia arising in BE. Aim To determine the safety and efficacy of RFA for treating dysplastic BE in a UK patient cohort.Study design Multicenter UK registry. Seven teaching and private hospitals; treatment period from April 2007 to November 2009.Methods Patients with histological evidence of dysplasia or intramucosal cancer (IMC) arising in BE confirmed by 2 specialist GI pathologists. A prior EMR was permitted, provided that residual dysplasia remained in the BE region for ablation. RFA was performed every 3 months with follow-up biopsy upon achieving either complete endoscopic eradication of BE or after 4 consecutive ablations. The primary endpoint was complete response for high grade dysplasia (CR-HGD), dysplasia (CR-D) and intestinal metaplasia (CR-IM), defined as no biopsy showing each respective finding.Results A total of 106 patients (79% male, median age 69 years, interquartile range {IQR} 50-83 years) have been treated so far. Accrual rates now exceed 15 patients per quarter. 83 had HGD, 22 IMC, 1 LGD. Median length of BE was 6cm (IQR 115cm). 54% had prior EMR, 25% had previous PDT or APC. 42 patients have completed treatment with at least 1 follow-up biopsy session (median follow-up 4 months, IQR 2-24). Median number of treatments is 1 CA (IQR 0-3) and 1 FA (IQR 0-3). CR-HGD was achieved in 90% of patients, CR-D in 79% and CR-IM in 33%. There were 8 new strictures, 3 mucosal injuries during RFA (1.5%) and 1 perforation (patient previously treated with PDT) (0.5%).Conclusion Reversal of IM is currently poor, but many of these patients have had multiple previous ablative therapies and may represent a particularly difficult group to treat. Despite this, radiofrequency ablation safely achieved a CR-HGD in 90% of patients treated within a UK multicenter registry. These data are similar to other registries.
S1494 Fully Covered, Retrievable Self-Expanding Metal Stents (Niti-S) in Palliation of Malignant Dysphagia Long-Term Results of a Prospective Study (10 Years) Jin Hong Kim, Sung Jun Choi, Jeong Woo Choi, Sung Jae Shin, Kee Myung Lee, Kwang Jae Lee, Sun Gyo Lim Background: The covered self expanding metal stent (SEMS) has become the main treatment option of malignant esophageal obstruction. However, the fully covered SEMS has not been as popular as the partially covered one for the fear of migration in spite of much advantage. So, we performed a prospective study to evaluate clinical efficacy of the fully covered SEMS. Methods: Between October 1998 and February 2009, 100 consecutive patients with malignant esophageal obstruction who were treated with the fully covered Niti-S stent (NitiS, Taewoong Medical, Seoul, Korea) were included. Data collected contained technical success rate of deployment and retrieval, dysphagia score changes, success rate of esophagorespiratory fistula (ERF) resolution, survival, stent patency and complications. We also conducted analyses concerning the associations between results and variables. Result: Technical success rate of stent
www.giejournal.org