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Sa1228 Prognosis of Vertical Margin Positive Endoscopic Submucosal Dissection (ESD) of Early Gastric Cancer (Egc)
Abstracts
Sa1227 Endoscopic Submucosal Dissection for Upper GI Submucosal Tumours Halim Awadie*1, David J. Tate1, Amir Klein1, Lobke Desomer1, Michael X. Ma1, Nicholas G. Burgess1,2, Eric Y. Lee1, Vu Kwan1,2, Michael J. Bourke1,2 1 Westmead hospital, Sydney, New South Wales, Australia; 2University of Sydney, Sydney, New South Wales, Australia
Sa1229 F-Calprotectin Use in Inflammatory Bowel Disease (IBD) Is Characterized by Improved Diagnostic Accuracy, Less Patient Harm and Decreased Costs, Compared With Conventional Serological Markers and Colonoscopy Barbara Mascialino*1, Veena Joy2, Anagh Vora2 1 ImmunoDiagnostics, Thermo Fisher Scientific, Uppsala, Sweden; 2 Thermo Fisher Scientific, Portage, MI
Introduction: Submucosal tumours (SMT) in the upper gastrointestinal tract (UGI) impose diagnostic and therapeutic challenges. They may have malignant potential and endoscopic ultrasound (EUS) guided diagnosis is often inaccurate. A substantial proportion may not involve the muscularis propria (MP) and thus may be amenable to endoscopic excision. Snare based techniques are usually unable to completely excise such lesions, though without complete excision ongoing endoscopic surveillance may be necessary. Endoscopic submucosal dissection (ESD) offers the possibility of complete resection and definitive histological diagnosis to guide management decisions. Western data on ESD for SMT is absent. Our aim was to analyse the data from our referral centre. Methods: A prospectively collected ESD database was analysed to identify patients with SMT of the UGI. All lesions underwent EUS assessment with the aim to exclude MP involvement prior to resection, and in the case of neuroendocrine tumours (NET) blood tests and Octreotate PET scan were performed. Results: Over 42 months, 30 ESDs for SMT lesions were performed. The mean age was 62 years with 19 male patients (63%). Mean lesion size was 18mm. Twenty five patients (83.3%) had completely resected tumours. Four patients (13%) had involvement of the MP which was identified during the resection, and one patient (3%) had MP injury which precluded complete resection. Three of five lesions of the incompletely ESD procedures were in the proximal body of the stomach, however only two lesions of the completely resected lesions were in the proximal body (P-0.004). Otherwise, there were no significant differences between the patients and lesions characteristics. The histology of the SMT lesions were 9 NET, 6 leiomyoma, 5 Granular cell tumours, four inflammatory fibroid polyp, 2 GIST, 2 dysplastic Lipoma, one myofibroblastic tumour and one Warthin’s like tumour. Nineteen patients had completed surveillance endoscopy (SE) without an endoscopic and histological recurrence (Median follow up 24 months). Six patients are pending SE. The four patients with deep MP involvement were referred for surgery. Conclusion: ESD for selected UGI SMT is an effective treatment. Long term endoscopic follow up confirmed the absence of recurrence endoscopically and histologically. MP involvement cannot be reliably excluded by prior EUS. This technique should be considered for UGI SMT lesions without MP involvement in experienced centres.
Gastrointestinal disorders may exhibit overlapping symptoms making diagnosis difficult in the primary and specialty care settings. Inflammatory bowel disease (IBD), with a prevalence of <0.5% in the general population, is characterized by chronic inflammation of the gastrointestinal tract, non-specific elevation of conventional inflammatory markers such as ESR and CRP and may present with extra-intestinal manifestations. Irritable bowel syndrome (IBS), in contrast, is a functional disorder without gastrointestinal inflammation and with an estimated prevalence of 10-20%. Endoscopy is the gold standard for detecting and quantifying IBD vs. IBS, but due to the low prevalence of IBD, is negative in the majority of cases. Furthermore, it is invasive, expensive, and uncomfortable for the patient and not without risks. Moreover, inadequate bowel preparation prior to colonoscopy is known to increase the burden of disease from both the clinical and the economic perspective: shorter intervals between repeated procedures, higher missed rates, patient inconvenience, and increased risk of complications are reported in the scientific literature. F-Calprotectin (FC) is a fecal marker of intestinal inflammation; IBD patients exhibit FC levels significantly higher than the general population; IBS patients have FC levels higher than healthy controls, but significantly lower than IBD patients. Therefore, FC can be used as a preendoscopic test to differentiate between IBD and IBS. The present study aims at evaluating the cost-effectiveness of a) FC compared to b) the combined usage of CRP and ESR, and c) colonoscopy to distinguish IBD from IBS in the US. Methodology: A Markov model was developed for each diagnostic strategy, simulating 1000 patients presenting to a primary care physician with non-specific gastrointestinal symptoms. In the model, 1.6% of the colonoscopies brought about complications (Rabasinghe, 2016), which may result in Emergency Room visits and surgery. Inadequate colon preparation (23%, - Kilgore, 2011) and consequent repeated colonoscopies (30.3% - Hendry, 2006) were also included in the calculations. Outcomes include cost savings, cost per corrected IBD diagnosed, and colonoscopy reduction. Uncertainty was addressed with sensitivity analysis. Findings: FC is cost-effective when compared to CRP+ESR, and to colonoscopy: -It results in more correctly IBD diagnoses at a lower price; -It reduces the number of unnecessary endoscopies, increasing the number of correctly diagnosed IBD (NZ63) and IBS (NZ26) patients. Conclusion: Results show that the usage of FC as pre-endoscopic diagnostic tool is associated with fewer colonoscopies and correctly identifies more disease while decreasing costs compared to the alternatives. Consequently, FC demonstrates superior value both from patient and payer perspective, while simultaneously increasing diagnostic efficacy.
Sa1228 Prognosis of Vertical Margin Positive Endoscopic Submucosal Dissection (ESD) of Early Gastric Cancer (Egc) Moonyong Eom*1, Wonjae Choi1, Moon Kyung Joo1, Beom Jae Lee1, Jong-Jae Park1, Hoon Jai Chun2, Sang Woo Lee3, Young-Tae Bak1 1 Korea University Guro Hospital, Seoul, Korea (the Republic of); 2Korea University Anam Hospital, Seoul, Korea (the Republic of); 3Korea University Ansan Hospital, Ansan, Korea (the Republic of) Background: Endoscopic submucosal dissection (ESD) is widely accepted as less invasive technique for early gastric cancer (EGC). If resected specimen shows positive vertical margin after ESD (vertical margin positive ESD), additional surgery is generally recommended, however, residual tumor rate and long term outcomes of endoscopic surveillance among patients with vertical margin positive ESD have not been reported. This study aimed to investigate the prognosis of EGC patients with positive vertical margin after ESD. Methods: We retrospectively reviewed the medical records of EGC patients who underwent ESD with positive vertical margins, but refused to undergo additional surgical resection. Results: From January 2007 to December 2013, a total of 50 patients had positive vertical margin after ESD, 15 patients (30.0%) received additional radical gastrectomy, and 35 cases (70.0%) were closely observed without surgery during 48.5 19.5 months. Among patients who underwent additional gastrectomy, four of 15 cases (26.7%) had residual cancer on resection specimen, whereas five of 35 cases (14.3%) had recurrence of tumor among the observed patients at 36.4 19.2 months after ESD. However, there were no statistical differences for sex, age, pathology, gross type, location, size, depth of invasion, lymphovascular invasion and indication of endoscopic resection between recurrence and non-recurrence group. Conclusions: In this study, approximately one-fourth of patients had residual tumor after vertical margin positive ESD. Predictable parameters for selecting patients to undergo additional surgery in case of positive vertical margin need to be evaluated in the future. Careful endoscopic surveillance may be considered if patient refused to undergo additional surgery.
AB210 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Clinical and health economics results Total costs ($) Average cost / patient ($) N colonoscopies avoided Colonoscopy costs avoided ($) N correctly diagnosed IBS N correctly diagnosed IBD Colonoscopy - complication costs ($)
F-Calprotectin
CRP+ESR
Colonoscopy
426 373 426.4 736 473 914 683 98 1 558
579 395 579.4 722 465 224 657 35 1 787
771 543 771.5 0 0 4 975
Sa1230 The Endoscopic Mucosal Resection of Sporadic Duodenal Polyps: A Decade of Experience From a Tertiary Referral Centre Mileidis San Juan-Acosta*1,2, Sabina Beg2, Jacobo Ortiz_Fernández-Sordo2, Adolfo Parra-Blanco2, Stefano Sansone2, Krish Ragunath2 1 Gastroenterology, University Hospital Nuestra Señora de Candelaria, Tenerife, Spain; 2Gastroenterology, NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham, United Kingdom Background and Aims: Endoscopic Mucosal Resection (EMR) offers a minimally invasive approach to the management of sporadic duodenal adenoma. However, there is limited data from the Western world on optimal management. We describe the largest European experience from a tertiary referral centre. Methods: A database review of all patients referred with sporadic duodenal adenoma from 2003 - 2016 in a tertiary referral endoscopy centre (Nottingham University Hospital-United Kingdom) was performed. Patient demographics, lesion characteristics (size, location, Paris classification and histopathology), procedural data, first follow-up at a mean 4 months, second surveillance 12 months and adverse events were evaluated. Results: Fifty-eight patients with sporadic duodenal adenoma were identified. 55
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Sa1227 Endoscopic Submucosal Dissection for Upper GI Submucosal Tumours Halim Awadie*1, David J. Tate1, Amir Klein1, Lobke Desomer1, Michael X. Ma1, Nicholas G. Burgess1,2, Eric Y. Lee1, Vu Kwan1,2, Michael J. Bourke1,2 1 Westmead hospital, Sydney, New South Wales, Australia; 2University of Sydney, Sydney, New South Wales, Australia
Sa1229 F-Calprotectin Use in Inflammatory Bowel Disease (IBD) Is Characterized by Improved Diagnostic Accuracy, Less Patient Harm and Decreased Costs, Compared With Conventional Serological Markers and Colonoscopy Barbara Mascialino*1, Veena Joy2, Anagh Vora2 1 ImmunoDiagnostics, Thermo Fisher Scientific, Uppsala, Sweden; 2 Thermo Fisher Scientific, Portage, MI
Introduction: Submucosal tumours (SMT) in the upper gastrointestinal tract (UGI) impose diagnostic and therapeutic challenges. They may have malignant potential and endoscopic ultrasound (EUS) guided diagnosis is often inaccurate. A substantial proportion may not involve the muscularis propria (MP) and thus may be amenable to endoscopic excision. Snare based techniques are usually unable to completely excise such lesions, though without complete excision ongoing endoscopic surveillance may be necessary. Endoscopic submucosal dissection (ESD) offers the possibility of complete resection and definitive histological diagnosis to guide management decisions. Western data on ESD for SMT is absent. Our aim was to analyse the data from our referral centre. Methods: A prospectively collected ESD database was analysed to identify patients with SMT of the UGI. All lesions underwent EUS assessment with the aim to exclude MP involvement prior to resection, and in the case of neuroendocrine tumours (NET) blood tests and Octreotate PET scan were performed. Results: Over 42 months, 30 ESDs for SMT lesions were performed. The mean age was 62 years with 19 male patients (63%). Mean lesion size was 18mm. Twenty five patients (83.3%) had completely resected tumours. Four patients (13%) had involvement of the MP which was identified during the resection, and one patient (3%) had MP injury which precluded complete resection. Three of five lesions of the incompletely ESD procedures were in the proximal body of the stomach, however only two lesions of the completely resected lesions were in the proximal body (P-0.004). Otherwise, there were no significant differences between the patients and lesions characteristics. The histology of the SMT lesions were 9 NET, 6 leiomyoma, 5 Granular cell tumours, four inflammatory fibroid polyp, 2 GIST, 2 dysplastic Lipoma, one myofibroblastic tumour and one Warthin’s like tumour. Nineteen patients had completed surveillance endoscopy (SE) without an endoscopic and histological recurrence (Median follow up 24 months). Six patients are pending SE. The four patients with deep MP involvement were referred for surgery. Conclusion: ESD for selected UGI SMT is an effective treatment. Long term endoscopic follow up confirmed the absence of recurrence endoscopically and histologically. MP involvement cannot be reliably excluded by prior EUS. This technique should be considered for UGI SMT lesions without MP involvement in experienced centres.
Gastrointestinal disorders may exhibit overlapping symptoms making diagnosis difficult in the primary and specialty care settings. Inflammatory bowel disease (IBD), with a prevalence of <0.5% in the general population, is characterized by chronic inflammation of the gastrointestinal tract, non-specific elevation of conventional inflammatory markers such as ESR and CRP and may present with extra-intestinal manifestations. Irritable bowel syndrome (IBS), in contrast, is a functional disorder without gastrointestinal inflammation and with an estimated prevalence of 10-20%. Endoscopy is the gold standard for detecting and quantifying IBD vs. IBS, but due to the low prevalence of IBD, is negative in the majority of cases. Furthermore, it is invasive, expensive, and uncomfortable for the patient and not without risks. Moreover, inadequate bowel preparation prior to colonoscopy is known to increase the burden of disease from both the clinical and the economic perspective: shorter intervals between repeated procedures, higher missed rates, patient inconvenience, and increased risk of complications are reported in the scientific literature. F-Calprotectin (FC) is a fecal marker of intestinal inflammation; IBD patients exhibit FC levels significantly higher than the general population; IBS patients have FC levels higher than healthy controls, but significantly lower than IBD patients. Therefore, FC can be used as a preendoscopic test to differentiate between IBD and IBS. The present study aims at evaluating the cost-effectiveness of a) FC compared to b) the combined usage of CRP and ESR, and c) colonoscopy to distinguish IBD from IBS in the US. Methodology: A Markov model was developed for each diagnostic strategy, simulating 1000 patients presenting to a primary care physician with non-specific gastrointestinal symptoms. In the model, 1.6% of the colonoscopies brought about complications (Rabasinghe, 2016), which may result in Emergency Room visits and surgery. Inadequate colon preparation (23%, - Kilgore, 2011) and consequent repeated colonoscopies (30.3% - Hendry, 2006) were also included in the calculations. Outcomes include cost savings, cost per corrected IBD diagnosed, and colonoscopy reduction. Uncertainty was addressed with sensitivity analysis. Findings: FC is cost-effective when compared to CRP+ESR, and to colonoscopy: -It results in more correctly IBD diagnoses at a lower price; -It reduces the number of unnecessary endoscopies, increasing the number of correctly diagnosed IBD (NZ63) and IBS (NZ26) patients. Conclusion: Results show that the usage of FC as pre-endoscopic diagnostic tool is associated with fewer colonoscopies and correctly identifies more disease while decreasing costs compared to the alternatives. Consequently, FC demonstrates superior value both from patient and payer perspective, while simultaneously increasing diagnostic efficacy.
Sa1228 Prognosis of Vertical Margin Positive Endoscopic Submucosal Dissection (ESD) of Early Gastric Cancer (Egc) Moonyong Eom*1, Wonjae Choi1, Moon Kyung Joo1, Beom Jae Lee1, Jong-Jae Park1, Hoon Jai Chun2, Sang Woo Lee3, Young-Tae Bak1 1 Korea University Guro Hospital, Seoul, Korea (the Republic of); 2Korea University Anam Hospital, Seoul, Korea (the Republic of); 3Korea University Ansan Hospital, Ansan, Korea (the Republic of) Background: Endoscopic submucosal dissection (ESD) is widely accepted as less invasive technique for early gastric cancer (EGC). If resected specimen shows positive vertical margin after ESD (vertical margin positive ESD), additional surgery is generally recommended, however, residual tumor rate and long term outcomes of endoscopic surveillance among patients with vertical margin positive ESD have not been reported. This study aimed to investigate the prognosis of EGC patients with positive vertical margin after ESD. Methods: We retrospectively reviewed the medical records of EGC patients who underwent ESD with positive vertical margins, but refused to undergo additional surgical resection. Results: From January 2007 to December 2013, a total of 50 patients had positive vertical margin after ESD, 15 patients (30.0%) received additional radical gastrectomy, and 35 cases (70.0%) were closely observed without surgery during 48.5 19.5 months. Among patients who underwent additional gastrectomy, four of 15 cases (26.7%) had residual cancer on resection specimen, whereas five of 35 cases (14.3%) had recurrence of tumor among the observed patients at 36.4 19.2 months after ESD. However, there were no statistical differences for sex, age, pathology, gross type, location, size, depth of invasion, lymphovascular invasion and indication of endoscopic resection between recurrence and non-recurrence group. Conclusions: In this study, approximately one-fourth of patients had residual tumor after vertical margin positive ESD. Predictable parameters for selecting patients to undergo additional surgery in case of positive vertical margin need to be evaluated in the future. Careful endoscopic surveillance may be considered if patient refused to undergo additional surgery.
AB210 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
Clinical and health economics results Total costs ($) Average cost / patient ($) N colonoscopies avoided Colonoscopy costs avoided ($) N correctly diagnosed IBS N correctly diagnosed IBD Colonoscopy - complication costs ($)
F-Calprotectin
CRP+ESR
Colonoscopy
426 373 426.4 736 473 914 683 98 1 558
579 395 579.4 722 465 224 657 35 1 787
771 543 771.5 0 0 4 975
Sa1230 The Endoscopic Mucosal Resection of Sporadic Duodenal Polyps: A Decade of Experience From a Tertiary Referral Centre Mileidis San Juan-Acosta*1,2, Sabina Beg2, Jacobo Ortiz_Fernández-Sordo2, Adolfo Parra-Blanco2, Stefano Sansone2, Krish Ragunath2 1 Gastroenterology, University Hospital Nuestra Señora de Candelaria, Tenerife, Spain; 2Gastroenterology, NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham, United Kingdom Background and Aims: Endoscopic Mucosal Resection (EMR) offers a minimally invasive approach to the management of sporadic duodenal adenoma. However, there is limited data from the Western world on optimal management. We describe the largest European experience from a tertiary referral centre. Methods: A database review of all patients referred with sporadic duodenal adenoma from 2003 - 2016 in a tertiary referral endoscopy centre (Nottingham University Hospital-United Kingdom) was performed. Patient demographics, lesion characteristics (size, location, Paris classification and histopathology), procedural data, first follow-up at a mean 4 months, second surveillance 12 months and adverse events were evaluated. Results: Fifty-eight patients with sporadic duodenal adenoma were identified. 55
www.giejournal.org