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S1518: Yield of Pre Ablation EUS for Barrett's Esophagus With High Grade Dysplasia
Abstracts human BE, the exact composition of bile acids affecting BE is still unknown. In the present study, we analyzed the composition of reflux bile acids from the stomach and investigated the relationship between their composition and erosive esophagitis or BE. Patients and Methods: This study included the consecutive 50 patients without BE, 50 patients with endoscopic BE of which the length was over 1 cm, and 15 patients with continuous administration of UDCA. EGD was performed on all participants and reflux bile was collected from the stomach. Biopsy samples were histologically evaluated for expression of COX-2, bone morphogenetic protein (BMP-4), as well as the presence of specialized columnar epithelium (SCE). The following two indices were calculated by the concentrations of 15 kinds of bile acids. The first was the reflux bile index 1 (RBI-1), defined by the ratio of hydrophobic bile acids to hydrophilic bile acids suggestive of cytoprotective action. The second was the reflux bile index 2 (RBI2), defined by the ratio of representative cytotoxic bile acids affecting BE proven by previous studies to hydrophilic bile acids. The relationships between these indices and clinico-pathological factors were evaluated.Results: RBI-1 showed statistically significant correlations with the presence of reflux esophagitis (t⫽0.306, p⫽0.024) and endoscopic BE (t⫽2.632, p⫽0.010). The correlation of RBI-1 with BMP-4 expression in esophageal squamous mucosa was also proven by Spearman’s rank correlation test (r⫽0.292, p⫽0.044). RBI-2 was confirmed to correlate with the presence of SCE (t⫽2.256, p⫽0.038), and shown a statistically significant correlation to COX-2 protein expression in Barrett’s glandular cells was proven (r⫽0.746, p⫽0.001). The influence of UDCA dose on both RBI-1 and 2 was also investigated, and statistically significant smaller values in both RBIs were found in cases with UDCA administration.Discussion and Conclusions: The increase of hydrophobic bile acids in gastric reflux bile acids was found to be closely related to the pathogenesis of erosive esophagitis and induction of BMP-4 expression with subsequent possible BE transformation. Cytotoxic bile acidinduced COX-2 expression was increased, suggesting possible malignant potential. In conclusion, changes in reflux bile acid composition from the stomach play an important role in the pathogenesis and carcinogenesis of BE. UDCA administration may prevent the outbreak of BE and Barrett’s carcinogenesis by changing reflux bile acid composition.
S1517 Complete Barrett’s Eradication Endoscopic Mucosal Resection (CBE-EMR): Long-Term Results of Management of High Grade Dysplasia (HGD) and Intramucosal Carcinoma (IMC) Jennifer S. Chennat, Vani J. Konda, John Hart, Shu-Yuan Xiao, Frank Caira, Mark K. Ferguson, Mitchell C. Posner, Marco G. Patti, Irving Waxman INTRODUCTION: CBE-EMR is endoscopic removal of all Barrett epithelium with the intent of eliminating high-grade dysplasia (HGD)/intramucosal carcinoma (IMC) and reducing the risk of metachronous lesion development. AIM: We report our tertiary referral center’s long-term experience using this modality in HGD/IMC management. METHODS: We reviewed our prospectively collected database of all patients who underwent CBE-EMR for Barrett esophagus (BE) with HGD/IMC. Prior to CBE-EMR, high-definition white-light/narrow-band imaging exams and staging endoscopic ultrasound were done to exclude invasive disease or suspicious lymphadenopathy. High-dose proton pump inhibitors were given after initial treatment. Seattle-type surveillance biopsies were obtained at 6-month intervals after completion of CBE-EMR therapy. RESULTS: 57 patients (age 66 ⫾ 10.8 years; 76% men) with histologically confirmed BE and HGD (39) or IMC (18) underwent CBE-EMR from August 2003 to November 2009. Mean BE segment length was 3.3 ⫾ 2.2 cm; 31 patients had short-segment BE, and 35 had visible lesions. A total of 143 EMR procedures were performed with 359 mucosectomy specimens obtained. On initial EMR, 3 patients had superficial submucosal carcinoma invasion (sm1) and 2 had IMC with lymphatic channel invasion. All 5 patients were referred for esophagectomy; 1 opted for continued endoscopic management and is without evidence of residual or recurrent carcinoma. 19 patients await completion of EMR (11) or first follow-up endoscopy (8). CBE-EMR therapy was completed in 34 patients in 1.5 ⫾ 0.8 sessions. Surveillance biopsies showed normal squamous epithelium in 31/34 (91.1%) patients (mean follow-up remission time 23.4 months (range 2-62). No patients developed recurrent IMC or invasive cancer. In all, 13/57 patients had subsquamous Barrett’s epithelium on EMR specimens and/or treatment endoscopy biopsies. CBE-EMR upstaged pre-EMR pathology results in 9 (16%) patients and downstaged pathology in 16 (28%) patients. In all, 25/53 (47%) patients developed symptomatic esophageal stenosis after a mean of 24.4 days; all were successfuly managed by endoscopic treatment. Significant bleeding and perforation occurred in 1 (1.8%) patient, which were successfully managed with endoscopic treatment. CONCLUSION: CBE-EMR with intensive endoscopic surveillance is an effective treatment modality for BE with HGD/IMC. Although the rate of stenosis development is high, it is easily treated by endoscopic methods. The role of CBE-EMR in patients with lymphatic invasion or superficial submucosal invasion remains to be defined.
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S1518 Yield of Pre Ablation EUS for Barrett’s Esophagus With High Grade Dysplasia John M. Iskander, Dayna S. Early, Riad R. Azar, Daniel Mullady, Sreenivasa S. Jonnalagadda, Christine E. Hovis, Steven A. Edmundowicz Introduction: Barrett’s esophagus with high grade dysplasia (BE HGD) can be managed with endoscopic ablative therapy. Some patients with BE HGD on endoscopic biopsies will harbor carcinoma, and endoscopic ultrasound (EUS) exam has been recommended prior to endoscopic ablative therapy in order to exclude findings suggestive of invasive cancer. The yield of EUS in this setting and the frequency with which EUS findings change the management plan is unknown. Methods:We retrospectively reviewed our database of all patients who were considered for endoscopic ablative therapy for non nodular BE HGD, who also underwent an EUS. Between 2005 (when our institution began performing ablative therapy) and 2009, a total of 126 patients were referred for possible ablative therapy of non nodular BE and underwent EUS exams. All subjects underwent probe or radial echoendoscope based examinations of the esophagus and proximal stomach to detect esophageal lesions and malignant adenopathy. Results:Of 126 patients, 104 (83%) underwent ablative therapy after EUS and 22 (17%) did not. Among the 22 patients, reasons for not pursuing ablative therapy were: finding at EUS of an abnormal lymph node (1), no HGD on repeat biopsy at the time of EUS (12), endoscopic mucosal resection (EMR) instead of ablation (5), invasive cancer (1), and non-endoscopic therapy (3). The patient found to have an abnormal lymph node underwent fine needle aspiration (FNA) demonstrating atypical cytology which prompted surgical treatment. This patient had a T1N0M0 cancer at esophagectomy. EUS findings in patients who subsequently underwent ablation included focal wall thickening in 47 patients (45%), paraesophageal lymph nodes in 33 patients (32%) and gastrohepatic or celiac lymph nodes in 4 patients (3.8%). FNA was performed in 5 lymph nodes; 4 were benign and 1 was atypical. EUS findings prior to ablative therapy of focal wall thickening or benign appearing lymph nodes did not alter therapeutic plans. There were no complications of EUS examination. Two patients progressed to cancer during follow up after ablation. Both had esophageal wall thickening on pre ablation EUS but no evidence of an invasive lesion and no lymphadenopathy.Conclusions: EUS can be easily and safely preformed in patients with BE HGD referred for ablative therapy. Many patients will have nonspecific findings of focal wall thickening or benign appearing lymph nodes. Rarely, EUS can identify malignant appearing nodes even in cases of non nodular BE HGD, which can lead to a significant change in management. Preablative EUS remains an important tool in selecting patients for ablative therapy of non nodular BE with HGD.
S1519 Closure of Iatrogenic Perforations, Tracheo-Esophageal Fistulas, and Post-Operative Leaks With Removable Internally Fully Covered Self Expandable Metal Stents Sahibzada U. Latif, Tercio Lopes, Mohamad A. Eloubeidi Background: Iatrogenic perforations (IP), tracheo-esophageal fistulas (TE fistulas) and post-operative leaks (PL) were traditionally treated surgically. Subsequently, partially-covered self expanding metallic stents (SEMS) and self-expanding plastic stents were also used. Generally, conventional SEMS cannot be removed and SEPS frequently migrate. Internally fully-covered self expandable metal stents (FCSEMS) have recently become available offering the possibility of removability. To our knowledge, the utility of FCSEMS and their success in closing IP, TE fistulas, and PL have not been fully investigated. Our aims were 1) to describe the success rates of FCSEMS in closing IP, TE fistulas and PL; 2) to assess success of removability of FCSEMS.Methods: FCSEMS (ALIMAXX-EE, Alveolus Inc, Charlotte, NC) were deployed in 26 consecutive patients with IP, TE fistulas, and PL over a period of 2 years. Dysphagia scores were assessed at 0, 1, 3 and 6 months. Complications and clinical outcomes were prospectively recorded. Follow up was complete on all patients. Results: Twenty six patients were treated for IP, TE fistulas, and PL with FCSEMS (mean age 59.5 years, 62% Caucasian, and 77% male). Indications for stents placement were: TE or gastrobronchial fistula (n⫽14, 54%), post-esophagectomy leak (n⫽7, 27 %), and esophageal perforation (n⫽5, 19 %). All stents were successfully inserted. Leaks or fistulas were located in the upper (n⫽8, 36%), mid (n⫽12, 55%), lower esophagus (n⫽1, 4.5%) and gastro-esophageal junction (n⫽1, 4.5%). Long term success in closing the defects was seen in 23/26 (88%). Only eleven patients (42%) were alive at the end of follow up. All others (58%) died due to their underlying illnesses. Dysphagia scores improved significantly at 1 month (mean difference 2.7; 2.1 to 3.2 95% CI, p⬍0.0001), 3 months (mean difference 2.9; 2.3 to 3.6 95% CI, p⬍0.0001) and 6 months (mean difference 3.1, 2.5 to 3.8 95% CI, P⬍0.0001) compared to baseline. Three patients experienced immediate complications after the procedure (respiratory compromise, chest pain, stent migration). Four patients experienced delayed complications: aspiration (n⫽2), globus sensation (n⫽1) and recurrent dysphagia (n⫽1). Sixteen (62%) stents were successfully removed: 13 were thought to have satisfied their purpose; 3 were removed due to failure to close the leak. Only one patient required surgery
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB183
S1517 Complete Barrett’s Eradication Endoscopic Mucosal Resection (CBE-EMR): Long-Term Results of Management of High Grade Dysplasia (HGD) and Intramucosal Carcinoma (IMC) Jennifer S. Chennat, Vani J. Konda, John Hart, Shu-Yuan Xiao, Frank Caira, Mark K. Ferguson, Mitchell C. Posner, Marco G. Patti, Irving Waxman INTRODUCTION: CBE-EMR is endoscopic removal of all Barrett epithelium with the intent of eliminating high-grade dysplasia (HGD)/intramucosal carcinoma (IMC) and reducing the risk of metachronous lesion development. AIM: We report our tertiary referral center’s long-term experience using this modality in HGD/IMC management. METHODS: We reviewed our prospectively collected database of all patients who underwent CBE-EMR for Barrett esophagus (BE) with HGD/IMC. Prior to CBE-EMR, high-definition white-light/narrow-band imaging exams and staging endoscopic ultrasound were done to exclude invasive disease or suspicious lymphadenopathy. High-dose proton pump inhibitors were given after initial treatment. Seattle-type surveillance biopsies were obtained at 6-month intervals after completion of CBE-EMR therapy. RESULTS: 57 patients (age 66 ⫾ 10.8 years; 76% men) with histologically confirmed BE and HGD (39) or IMC (18) underwent CBE-EMR from August 2003 to November 2009. Mean BE segment length was 3.3 ⫾ 2.2 cm; 31 patients had short-segment BE, and 35 had visible lesions. A total of 143 EMR procedures were performed with 359 mucosectomy specimens obtained. On initial EMR, 3 patients had superficial submucosal carcinoma invasion (sm1) and 2 had IMC with lymphatic channel invasion. All 5 patients were referred for esophagectomy; 1 opted for continued endoscopic management and is without evidence of residual or recurrent carcinoma. 19 patients await completion of EMR (11) or first follow-up endoscopy (8). CBE-EMR therapy was completed in 34 patients in 1.5 ⫾ 0.8 sessions. Surveillance biopsies showed normal squamous epithelium in 31/34 (91.1%) patients (mean follow-up remission time 23.4 months (range 2-62). No patients developed recurrent IMC or invasive cancer. In all, 13/57 patients had subsquamous Barrett’s epithelium on EMR specimens and/or treatment endoscopy biopsies. CBE-EMR upstaged pre-EMR pathology results in 9 (16%) patients and downstaged pathology in 16 (28%) patients. In all, 25/53 (47%) patients developed symptomatic esophageal stenosis after a mean of 24.4 days; all were successfuly managed by endoscopic treatment. Significant bleeding and perforation occurred in 1 (1.8%) patient, which were successfully managed with endoscopic treatment. CONCLUSION: CBE-EMR with intensive endoscopic surveillance is an effective treatment modality for BE with HGD/IMC. Although the rate of stenosis development is high, it is easily treated by endoscopic methods. The role of CBE-EMR in patients with lymphatic invasion or superficial submucosal invasion remains to be defined.
www.giejournal.org
S1518 Yield of Pre Ablation EUS for Barrett’s Esophagus With High Grade Dysplasia John M. Iskander, Dayna S. Early, Riad R. Azar, Daniel Mullady, Sreenivasa S. Jonnalagadda, Christine E. Hovis, Steven A. Edmundowicz Introduction: Barrett’s esophagus with high grade dysplasia (BE HGD) can be managed with endoscopic ablative therapy. Some patients with BE HGD on endoscopic biopsies will harbor carcinoma, and endoscopic ultrasound (EUS) exam has been recommended prior to endoscopic ablative therapy in order to exclude findings suggestive of invasive cancer. The yield of EUS in this setting and the frequency with which EUS findings change the management plan is unknown. Methods:We retrospectively reviewed our database of all patients who were considered for endoscopic ablative therapy for non nodular BE HGD, who also underwent an EUS. Between 2005 (when our institution began performing ablative therapy) and 2009, a total of 126 patients were referred for possible ablative therapy of non nodular BE and underwent EUS exams. All subjects underwent probe or radial echoendoscope based examinations of the esophagus and proximal stomach to detect esophageal lesions and malignant adenopathy. Results:Of 126 patients, 104 (83%) underwent ablative therapy after EUS and 22 (17%) did not. Among the 22 patients, reasons for not pursuing ablative therapy were: finding at EUS of an abnormal lymph node (1), no HGD on repeat biopsy at the time of EUS (12), endoscopic mucosal resection (EMR) instead of ablation (5), invasive cancer (1), and non-endoscopic therapy (3). The patient found to have an abnormal lymph node underwent fine needle aspiration (FNA) demonstrating atypical cytology which prompted surgical treatment. This patient had a T1N0M0 cancer at esophagectomy. EUS findings in patients who subsequently underwent ablation included focal wall thickening in 47 patients (45%), paraesophageal lymph nodes in 33 patients (32%) and gastrohepatic or celiac lymph nodes in 4 patients (3.8%). FNA was performed in 5 lymph nodes; 4 were benign and 1 was atypical. EUS findings prior to ablative therapy of focal wall thickening or benign appearing lymph nodes did not alter therapeutic plans. There were no complications of EUS examination. Two patients progressed to cancer during follow up after ablation. Both had esophageal wall thickening on pre ablation EUS but no evidence of an invasive lesion and no lymphadenopathy.Conclusions: EUS can be easily and safely preformed in patients with BE HGD referred for ablative therapy. Many patients will have nonspecific findings of focal wall thickening or benign appearing lymph nodes. Rarely, EUS can identify malignant appearing nodes even in cases of non nodular BE HGD, which can lead to a significant change in management. Preablative EUS remains an important tool in selecting patients for ablative therapy of non nodular BE with HGD.
S1519 Closure of Iatrogenic Perforations, Tracheo-Esophageal Fistulas, and Post-Operative Leaks With Removable Internally Fully Covered Self Expandable Metal Stents Sahibzada U. Latif, Tercio Lopes, Mohamad A. Eloubeidi Background: Iatrogenic perforations (IP), tracheo-esophageal fistulas (TE fistulas) and post-operative leaks (PL) were traditionally treated surgically. Subsequently, partially-covered self expanding metallic stents (SEMS) and self-expanding plastic stents were also used. Generally, conventional SEMS cannot be removed and SEPS frequently migrate. Internally fully-covered self expandable metal stents (FCSEMS) have recently become available offering the possibility of removability. To our knowledge, the utility of FCSEMS and their success in closing IP, TE fistulas, and PL have not been fully investigated. Our aims were 1) to describe the success rates of FCSEMS in closing IP, TE fistulas and PL; 2) to assess success of removability of FCSEMS.Methods: FCSEMS (ALIMAXX-EE, Alveolus Inc, Charlotte, NC) were deployed in 26 consecutive patients with IP, TE fistulas, and PL over a period of 2 years. Dysphagia scores were assessed at 0, 1, 3 and 6 months. Complications and clinical outcomes were prospectively recorded. Follow up was complete on all patients. Results: Twenty six patients were treated for IP, TE fistulas, and PL with FCSEMS (mean age 59.5 years, 62% Caucasian, and 77% male). Indications for stents placement were: TE or gastrobronchial fistula (n⫽14, 54%), post-esophagectomy leak (n⫽7, 27 %), and esophageal perforation (n⫽5, 19 %). All stents were successfully inserted. Leaks or fistulas were located in the upper (n⫽8, 36%), mid (n⫽12, 55%), lower esophagus (n⫽1, 4.5%) and gastro-esophageal junction (n⫽1, 4.5%). Long term success in closing the defects was seen in 23/26 (88%). Only eleven patients (42%) were alive at the end of follow up. All others (58%) died due to their underlying illnesses. Dysphagia scores improved significantly at 1 month (mean difference 2.7; 2.1 to 3.2 95% CI, p⬍0.0001), 3 months (mean difference 2.9; 2.3 to 3.6 95% CI, p⬍0.0001) and 6 months (mean difference 3.1, 2.5 to 3.8 95% CI, P⬍0.0001) compared to baseline. Three patients experienced immediate complications after the procedure (respiratory compromise, chest pain, stent migration). Four patients experienced delayed complications: aspiration (n⫽2), globus sensation (n⫽1) and recurrent dysphagia (n⫽1). Sixteen (62%) stents were successfully removed: 13 were thought to have satisfied their purpose; 3 were removed due to failure to close the leak. Only one patient required surgery
Volume 71, No. 5 : 2010 GASTROINTESTINAL ENDOSCOPY AB183