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Sa1386 Endoscopic Stapling in Comparison to Laparoscopic Fundoplication for the Treatment of Gastroesophageal Reflux Disease
SATURDAY POSTER ABSTRACTS
Sa1384 The Value of Chest CT Scan After PerOral Endoscopic Myotomy in Achalasia Patients Ming-Yan Cai, Zhou Pinghong*, LI-Qing Yao, Mei-Dong Xu, Quan-Lin LI, Yi-Qun Zhang, Wei-Feng Chen, Zhong Ren, Wen-Zheng Qin, Jian-Wei Hu Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China
Conclusions: Apparently, in the development of the MWT in some patients acts as negative gastroesophageal reflux disease. Using the submucosal infiltration of 20 ml of 1% solution of H2O2 in the cardia can improve the quality of life for patients with refractory GERD.
Background and Objectives: Peroral endoscopic myotomy (POEM) is a new endoscopic method for treatment of achalasia. The aim of this study was to verify the clinical value of routine postoperative chest CT scan for detection of sequelae and complications after peroral endoscopic myotomy (POEM) procedure. Patients and Methods: A retrospective review was performed in the Endoscopy Center, Zhongshan Hospital of Fudan University. Data of those who successfully underwent POEM and had a chest CT scan performed on postoperative day 1 from August 2010 to July 2012 was collected. A total of 300 patients (male/female 146/154; mean age 39.4⫾14.8 years) were included. We studied the association between the CT findings and clinical and technical factors by uni- and multivariate analysis. Results: The main CT findings were pneumothorax (50/300), pleural effusion (unilateral, 62/300; bilateral, 138/300), pneumonia (unilateral, 69/300; bilateral, 89/300), pneumoperitoneum (113/300), focal atelectasis (63/300), mediastinal emphysema (145/300), subcutaneous emphysema (86/300). Among those who had pneumothorax, 17/50 patients needed intervention. Only 1% of patients (2/200) with pleural effusion needed intervention. The spontaneous absorption of the effusion was observed. Other findings on CT scans were minor problems and did not need further intervention. In one patient a hematoma was observed on CT scan before any clinical manifestation occurred. The patient received an emergency endoscopy. Uni- and multivariate analysis of related factors identified that older patients had a higher risk for pneumothorax according to the CT scan results. Furthermore, the use of CO2 gas (versus room air) insufflation is a significant independent factor for pneumothorax (P⬍0.001; 95% CI, 0.012-0.157), for pneumoperitoneum (P⬍0.001; 95% CI, 0.170-0.082), for mediastinal emphysema (P⬍0.001; 95% CI, 0.033-0.185) and for subcutaneous emphysema (P⬍0.001; 95% CI, 0.060-0.309). Full-thickness myotomy did not increase the risk of any of these events. Interestingly, women were more susceptible to have mediastinal and subcutaneous emphysema than men. (P⫽0.038, 0.011, respectively). Conclusion: Chest CT scan for achalasia patients who received POEM procedure can be used to detect early signs of postoperative bleeding, but routine application is probably not warranted. The role in guiding management of post-POEM pneumothorax who need intervention has to be studied further.
Sa1385 8 Years Experience of Endoscopic Treatment of Refractory GERD Alexey Korotkevich* Endoscopy, Advanced Medical School for Doctors, Novokuznetsk, Russian Federation Background: There is a part of patients with methods of medical or surgical treatment can not achieve remission of reflux disease. Aims: We investigated results of endoscopic hemostasis as justification of new endoscopic treatment of refractory GERD and follow up results. Materials and methods: Justification of the method of treatment of refractory GERD: blind, randomized evaluation of hemostatic infiltration depending on solution used from 2000 to 2004 was performed in 205 patients with Mallory-Weiss tears (MWT). Direct endoscopic response was assessed by endoscopic monitoring after 6-8 hours of primary hemostasis. Used a 1% solution of 20 ml of H2O2 (79 patients) and 50 ml of saline (126 patients). The results of clinical and endoscopic assessment formed the basis for the treatment of refractory GERD. In 2004-2010 25 patients with refractory GERD received treatment session of submucosal infiltration of 1% solution of H2O2 (20 mL). Hiatus hernia was present in 10 patients, and the cardia incompetence in 15 patients. Control endoscopy and a survey carried out in 10 days, 6 months and annually. Results: After hemostasis by 1% solution of H2O2 at MWT restore contractile cardia was in 61 cases (70%) with saline in 55 (44%) (2 ⫽ 22,27 (df ⫽ 1) p ⫽ 0,0000). After hemostasis by 1% solution of H2O2 under MWT regression heartburn was in 36 cases (92%) to 2 (6%) (2 ⫽ 43,88 (df ⫽ 1) p ⫽ 0,0000), dose reduction or waiver of the drugs in 13 (68%) versus 1 (7%) (2 ⫽ 12,39 (df ⫽ 1) p ⫽ 0,0004). In assessing the results of treatment of refractory GERD at 2, 4, 6 and 8 years of complaints relapsed significantly lower intensity in 12 patients (48%) (ANOVA Chi Sqr. (N ⫽ 3, df ⫽ 3) ⫽ 8,333333 p ⬍, 03960; Coeff. of Concordance ⫽, 92,593 Aver. rank r ⫽0, 88889); cardia relaxation in 8 cases (61%) (ANOVA Chi Sqr. (N ⫽ 3, df ⫽ 3) ⫽ 8,464286 p ⬍, 03733; Coeff. of Concordance ⫽, 94,048 Aver. rank r ⫽, 91071).
Sa1386 Endoscopic Stapling in Comparison to Laparoscopic Fundoplication for the Treatment of Gastroesophageal Reflux Disease Ahmet Danalioglu*1, Gokhan Cipe2, Toygar Toydemir3, Orhan Kocaman1, Ali T. Ince1, Mahmut Muslumanoglu2, Hakan Senturk1 1 Gastroenterology, Bezmialem Vakif University, Faculty of Medicine, Istanbul, Turkey; 2General Surgery, Bezmialem Vakif University, Faculty of Medicine, Istanbul, Turkey; 3General Surgery, Surgery Hospital of Istanbul, Istanbul, Turkey Background and study aims: The SRS Endoscopic Stapling System (Medigus Ltd, Omer, Israel), a recently designed anti-reflux treatment capable of creating a totally endoscopic partial fundoplication, has been suggested as a non-surgical reconstruction method for the failing barrier between the esophagus and stomach. Laparoscopic anti-reflux surgery (LARS) gives successful results with minimal morbidity, but its surgical nature motivated the exploration of new, more practical endoscopic methods that do not require an operating theater. The aim of this study is to compare the outcome of the SRS Endoscopic Stapling System (SRS) with LARS in patients with gastroesophageal reflux disease (GERD). Patients and Methods: A total of 27 patients with GERD were treated between September and December 2011. Eleven patients underwent SRS, and 16 patients, LARS. Data on all patients, including demographics, perioperative details,
AB186 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org
Abstracts
postoperative complications, and early outcome, were collected prospectively and evaluated using SPSS software. Patients’ symptom status were assessed using Velanovich gastroesophageal health related quality of life (GERD-HRQL) scores. The Chi-square and Mann Witney-U tests were used for statistical analysis. Results: Of the 16 (59.3%) male and 11 (40.7%) female patients, mean age was 39.6 (range: 24-60) years and mean body mass index was 26.2 kg/m2. Groups were similar as to gender, age, and body mass index. None of the LARS cases were converted to open surgery. The one esophageal perforation observed in the SRS group was completely resolved by over-the-scope clipping (OTSC Ovesco Endoscopy AG. Tübingen, Germany). The duration of procedures for SRS and LARS were 89 and 47 minutes, respectively (p⬍0.05). The mean discharge time was longer for the LARS group (1.2 days) than for the SRS group (3 days, p⬍0.05); however— excluding the complicated patient in SRS group who stayed for 21 days—length of hospital stay was almost identical in both groups: 1.1 and 1.2 days, respectively (p⬍0.05). During the 6 months mean follow-up, bloating and dysphagia rates were similar between the groups (p⬎0.05). Rate of postoperative PPI usage was insignificantly higher in the SRS group (27.3%) than in the LARS (6.3%) (p⬎0.05). The mean GERD HRQL scores dropped from 29.3 to 4.1 and 24.8 to 8.9 in LARS and SRS groups, respectively (p⬍0.05). Conclusions: The short term results of SRS are promising. New generations of SRS, soon to be undergoing trials, and increasing experience may further improve results and decrease the untoward effects. Key Words: Reflux disease, endoscopic therapy.
Sa1387 A Randomised Trial Comparing Multiband Mucosectomy and ER-CAP for Endoscopic Piecemeal Resection of Early Squamous Neoplasia of the Esophagus Yueming Zhang1, David F. Boerwinkel*2, Shun He1, Liyan Xue3, Bas L. Weusten2,4, Sanford M. Dawsey5, David E. Fleischer6, Xiumin Qin1, Lizhou Dou1, Yong Liu1, Lu Ning3, Jacques J. Bergman2, Guiqi Wang1 1 Endoscopy, Cancer Institute and Hospital, Chinese Academy of Sciences, Beijing, China; 2Gastroenterology and Hepatology, Academic Medical Centre Amsterdam, Amsterdam, Netherlands; 3Pathology, Cancer Institute and Hospital, Chinese Academy of Sciences, Beijing, China; 4Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands; 5Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD; 6Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ Introduction: Endoscopic Resection (ER) for esophageal high-grade intraepithelial neoplasia (HGIN) or esophageal squamous cell carcinoma (ESCC) is usually performed with the ER-cap technique. This requires submucosal lifting and multiple snares for piecemeal resections and is therefore technically relatively difficult. Multi Band Mucosectomy (MBM) is an ER technique that uses a modified variceal-band ligator for piecemeal resection without submucosal lifting. In China, in certain high-risk areas where ESCC is extremely prevalent and limited endoscopic expertise is available, MBM might be a more easily applicable ER technique. Aim: We prospectively compared MBM to ER-cap for piecemeal ER of squamous neoplasia of the esophagus. Methods: Patients with HGIN or ESCC (size ⱖ2, ⱕ6 cm, max 2/3 of the circumference) and no signs of submucosal invasion or metastatic disease were included. Lesions were delineated with electrocoagulation after 1.25% Lugol staining. The patient was then randomised to MBM or ER-cap followed by piecemeal resection. Endpoints: complete endoscopic resection (ie complete removal of the lesion including all electrocoagulation markers), procedure time, costs, adverse events, absence of HGIN/ESCC at 3 months follow-up. Calculated sample size: 84 patients. Results: In 88 patients (62 male, mean age 60 yrs) ER was performed with MBM (n⫽46, 12 ESCC) or ER-cap (n⫽42, 13 ESCC). There was no difference in the size of lesions between groups (5cm vs. 5cm, p⫽NS; 42% vs. 33% of the circumference, p⫽NS). Endoscopic complete resection was achieved in all lesions. Procedure time was less with MBM (11 vs. 22 minutes, p⬍0.001), for a median of 5 vs. 4 resections (p⫽0.03). MBM resulted in smaller (18x12mm vs. 20x15mm; p⫽NS), but thicker (2200 m vs. 1700m; p⫽0.04) resection specimens. No difference in submucosal thickness was observed (900 m vs. 800 m; p⫽NS). Four patients were referred for surgery, based on the ER histology. Total costs of disposables was significantly less for MBM compared with ER-cap ($260 vs. $325, p⫽0.04).No clinically significant bleeding episodes occurred. One perforation was seen after ER-cap, which was treated conservatively. No clinically relevant stenoses were observed.At 3 months FU none of the patients demonstrated HGIN/ESCC at the resection site. Conclusion: Piecemeal ER of early esophageal squamous neoplasia with MBM is faster and cheaper compared to ER-cap. Both techniques are highly effective and safe. Given its low complexity and costs, MBM may have significant advantages over the ER-cap technique, especially in countries where ESCC is highly prevalent but endoscopic expertise and resources are limited.
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Patient, lesion and procedure characteristics Patients Age - years (SD) Gender - male : female Histology lesion pre-ER HGIN ESCC Lesion size cm % of circumference Procedure time - minutes Number of resections Size of ER specimens - mm Histology ER specimen LGIN MGIN HGIN ESCC Thickness of ER specimens (m) Submucosal thickness (m) Costs of disposables (\$) Histology ER site (3 mo FU) Squamous LGIN
MBM
ER-cap
p-value
46 60 (7) 31 : 15 34 12 5 42 11 5 18⫻12
42 59 (8) 31 : 11 29 13 5 33 22 4 20⫻15
NS NS NS NS NS NS NS ⬍0.001 0.03 NS
1 3 16 26 2200 900 260 32 8
2 2 17 21 1700 800 325 32 35
NS NS NS NS 0.04 NS 0.04 NS NS
Sa1388 Low Pressure Cryospray Ablation of High Grade Dysplasia in Barrett’s Esophagus: 2 Year Follow-up Mark H. Johnston* Gastroenterology, Lancaster Gastroenterology Inc., Lancaster, PA Background: Endoscopic ablation is currently the preferred modality for the treatment of high-grade dysplasia (HGD) in Barrett’s esophagus (BE). Objective: To assess the safety, efficacy and durability of low-pressure cryospray ablation using liquid nitrogen in the treatment of HGD in BE over a 2 year follow up period.DESIGN: Single center, nonrandomized cohort study. Technique: cryospray ablation every 8 weeks using two 20 second circumferential ablations with one minute thaws. Patients: Patients with BE and HGD. Age, length of BE, and previous ablation were not exclusion criteria Main Outcome Measurements: (1)Complete eradication of HGD, (2) complete eradication of non-dysplastic intestinal metaplasia. Results: Twenty patients with HGD in BE who refused other treatment options were treated with low pressure cryospray ablation. The mean follow-up status-post last cryospray ablation was 2 years. Nineteen of 20 patients (95%) had complete elimination of all dysplasia. Fifty-five percent had complete elimination of all nondysplastic intestinal metaplasia. Mean length of BE prior to treatment was 5 cm with a range from 11 to 1 cm. The average number treatments were 4. Complications included 2 mild esophageal strictures treated with single dilation and one bleed in a patient resuming coumadin immediately after treatment. Conclusions: Low-pressure cryospray ablation of HGD in BE using liquid nitrogen is highly effective, safe and durable over at least a two year follow-up period.
Sa1389 Endoscopic Closure of Large Mucosal Defects Post Endoscopic Submucosal Dissection (ESD) Eliminates the Need for Hospital Admission Sergey Kantsevoy*, Marianne Bitner, Lisa Turnbough, Sanjay Jagannath, Anurag Maheshwari, Paul J. Thuluvath Institute for Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, MD Background: Endoscopic submucosal dissection (ESD) is gaining popularity around the World. Although it is much less invasive then laparoscopic or open surgery, patients post ESD require bowel rest and hospitalization for several days to provide optimal healing conditions for large defects created after ESD. Aim: To evaluate the use of newly developed endoscopic suturing device for closure of large mucosal defects post ESD. Methods: All procedures were performed using submucosal injection of normal saline followed by resection of the lesions utilizing ESD technique with dual knife (Olympus Medical, LTD, Tokyo, Japan). After completion of the ESD, the resulting large mucosal defects were completely closed with Overstitch endoscopic suturing device (Apollo Endosurgery, Inc, Austin, TX). All patients were discharged home post procedures with subsequent clinical and endoscopic follow-up. Results: For the last 4 months, ESD with subsequent endoscopic suturing of mucosal defect were performed in 9 patients (3 - stomach, 6 - colon). Mean age of the patients was 63.8⫾14.5 years. Average size of the lesions was 37.8⫾10.3 mm. All lesions were removed en block. Suturing with endoscopic suturing device was technically easy and required only 1 stitch (continuous suturing line) for complete closure in 7 patients. In other 2 patients mucosal defect post ESD was closed with 2 separate stitches. There were no immediate or delayed complications in any of the study patients. Conclusion: Closure of the post-ESD defects with endoscopic suturing device is technically easy, safe, and eliminates the need for hospital admission. Endoscopic closure of post-ESD defects will especially benefit patients requiring therapeutic anticoagulation.
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB187
Sa1384 The Value of Chest CT Scan After PerOral Endoscopic Myotomy in Achalasia Patients Ming-Yan Cai, Zhou Pinghong*, LI-Qing Yao, Mei-Dong Xu, Quan-Lin LI, Yi-Qun Zhang, Wei-Feng Chen, Zhong Ren, Wen-Zheng Qin, Jian-Wei Hu Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China
Conclusions: Apparently, in the development of the MWT in some patients acts as negative gastroesophageal reflux disease. Using the submucosal infiltration of 20 ml of 1% solution of H2O2 in the cardia can improve the quality of life for patients with refractory GERD.
Background and Objectives: Peroral endoscopic myotomy (POEM) is a new endoscopic method for treatment of achalasia. The aim of this study was to verify the clinical value of routine postoperative chest CT scan for detection of sequelae and complications after peroral endoscopic myotomy (POEM) procedure. Patients and Methods: A retrospective review was performed in the Endoscopy Center, Zhongshan Hospital of Fudan University. Data of those who successfully underwent POEM and had a chest CT scan performed on postoperative day 1 from August 2010 to July 2012 was collected. A total of 300 patients (male/female 146/154; mean age 39.4⫾14.8 years) were included. We studied the association between the CT findings and clinical and technical factors by uni- and multivariate analysis. Results: The main CT findings were pneumothorax (50/300), pleural effusion (unilateral, 62/300; bilateral, 138/300), pneumonia (unilateral, 69/300; bilateral, 89/300), pneumoperitoneum (113/300), focal atelectasis (63/300), mediastinal emphysema (145/300), subcutaneous emphysema (86/300). Among those who had pneumothorax, 17/50 patients needed intervention. Only 1% of patients (2/200) with pleural effusion needed intervention. The spontaneous absorption of the effusion was observed. Other findings on CT scans were minor problems and did not need further intervention. In one patient a hematoma was observed on CT scan before any clinical manifestation occurred. The patient received an emergency endoscopy. Uni- and multivariate analysis of related factors identified that older patients had a higher risk for pneumothorax according to the CT scan results. Furthermore, the use of CO2 gas (versus room air) insufflation is a significant independent factor for pneumothorax (P⬍0.001; 95% CI, 0.012-0.157), for pneumoperitoneum (P⬍0.001; 95% CI, 0.170-0.082), for mediastinal emphysema (P⬍0.001; 95% CI, 0.033-0.185) and for subcutaneous emphysema (P⬍0.001; 95% CI, 0.060-0.309). Full-thickness myotomy did not increase the risk of any of these events. Interestingly, women were more susceptible to have mediastinal and subcutaneous emphysema than men. (P⫽0.038, 0.011, respectively). Conclusion: Chest CT scan for achalasia patients who received POEM procedure can be used to detect early signs of postoperative bleeding, but routine application is probably not warranted. The role in guiding management of post-POEM pneumothorax who need intervention has to be studied further.
Sa1385 8 Years Experience of Endoscopic Treatment of Refractory GERD Alexey Korotkevich* Endoscopy, Advanced Medical School for Doctors, Novokuznetsk, Russian Federation Background: There is a part of patients with methods of medical or surgical treatment can not achieve remission of reflux disease. Aims: We investigated results of endoscopic hemostasis as justification of new endoscopic treatment of refractory GERD and follow up results. Materials and methods: Justification of the method of treatment of refractory GERD: blind, randomized evaluation of hemostatic infiltration depending on solution used from 2000 to 2004 was performed in 205 patients with Mallory-Weiss tears (MWT). Direct endoscopic response was assessed by endoscopic monitoring after 6-8 hours of primary hemostasis. Used a 1% solution of 20 ml of H2O2 (79 patients) and 50 ml of saline (126 patients). The results of clinical and endoscopic assessment formed the basis for the treatment of refractory GERD. In 2004-2010 25 patients with refractory GERD received treatment session of submucosal infiltration of 1% solution of H2O2 (20 mL). Hiatus hernia was present in 10 patients, and the cardia incompetence in 15 patients. Control endoscopy and a survey carried out in 10 days, 6 months and annually. Results: After hemostasis by 1% solution of H2O2 at MWT restore contractile cardia was in 61 cases (70%) with saline in 55 (44%) (2 ⫽ 22,27 (df ⫽ 1) p ⫽ 0,0000). After hemostasis by 1% solution of H2O2 under MWT regression heartburn was in 36 cases (92%) to 2 (6%) (2 ⫽ 43,88 (df ⫽ 1) p ⫽ 0,0000), dose reduction or waiver of the drugs in 13 (68%) versus 1 (7%) (2 ⫽ 12,39 (df ⫽ 1) p ⫽ 0,0004). In assessing the results of treatment of refractory GERD at 2, 4, 6 and 8 years of complaints relapsed significantly lower intensity in 12 patients (48%) (ANOVA Chi Sqr. (N ⫽ 3, df ⫽ 3) ⫽ 8,333333 p ⬍, 03960; Coeff. of Concordance ⫽, 92,593 Aver. rank r ⫽0, 88889); cardia relaxation in 8 cases (61%) (ANOVA Chi Sqr. (N ⫽ 3, df ⫽ 3) ⫽ 8,464286 p ⬍, 03733; Coeff. of Concordance ⫽, 94,048 Aver. rank r ⫽, 91071).
Sa1386 Endoscopic Stapling in Comparison to Laparoscopic Fundoplication for the Treatment of Gastroesophageal Reflux Disease Ahmet Danalioglu*1, Gokhan Cipe2, Toygar Toydemir3, Orhan Kocaman1, Ali T. Ince1, Mahmut Muslumanoglu2, Hakan Senturk1 1 Gastroenterology, Bezmialem Vakif University, Faculty of Medicine, Istanbul, Turkey; 2General Surgery, Bezmialem Vakif University, Faculty of Medicine, Istanbul, Turkey; 3General Surgery, Surgery Hospital of Istanbul, Istanbul, Turkey Background and study aims: The SRS Endoscopic Stapling System (Medigus Ltd, Omer, Israel), a recently designed anti-reflux treatment capable of creating a totally endoscopic partial fundoplication, has been suggested as a non-surgical reconstruction method for the failing barrier between the esophagus and stomach. Laparoscopic anti-reflux surgery (LARS) gives successful results with minimal morbidity, but its surgical nature motivated the exploration of new, more practical endoscopic methods that do not require an operating theater. The aim of this study is to compare the outcome of the SRS Endoscopic Stapling System (SRS) with LARS in patients with gastroesophageal reflux disease (GERD). Patients and Methods: A total of 27 patients with GERD were treated between September and December 2011. Eleven patients underwent SRS, and 16 patients, LARS. Data on all patients, including demographics, perioperative details,
AB186 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org
Abstracts
postoperative complications, and early outcome, were collected prospectively and evaluated using SPSS software. Patients’ symptom status were assessed using Velanovich gastroesophageal health related quality of life (GERD-HRQL) scores. The Chi-square and Mann Witney-U tests were used for statistical analysis. Results: Of the 16 (59.3%) male and 11 (40.7%) female patients, mean age was 39.6 (range: 24-60) years and mean body mass index was 26.2 kg/m2. Groups were similar as to gender, age, and body mass index. None of the LARS cases were converted to open surgery. The one esophageal perforation observed in the SRS group was completely resolved by over-the-scope clipping (OTSC Ovesco Endoscopy AG. Tübingen, Germany). The duration of procedures for SRS and LARS were 89 and 47 minutes, respectively (p⬍0.05). The mean discharge time was longer for the LARS group (1.2 days) than for the SRS group (3 days, p⬍0.05); however— excluding the complicated patient in SRS group who stayed for 21 days—length of hospital stay was almost identical in both groups: 1.1 and 1.2 days, respectively (p⬍0.05). During the 6 months mean follow-up, bloating and dysphagia rates were similar between the groups (p⬎0.05). Rate of postoperative PPI usage was insignificantly higher in the SRS group (27.3%) than in the LARS (6.3%) (p⬎0.05). The mean GERD HRQL scores dropped from 29.3 to 4.1 and 24.8 to 8.9 in LARS and SRS groups, respectively (p⬍0.05). Conclusions: The short term results of SRS are promising. New generations of SRS, soon to be undergoing trials, and increasing experience may further improve results and decrease the untoward effects. Key Words: Reflux disease, endoscopic therapy.
Sa1387 A Randomised Trial Comparing Multiband Mucosectomy and ER-CAP for Endoscopic Piecemeal Resection of Early Squamous Neoplasia of the Esophagus Yueming Zhang1, David F. Boerwinkel*2, Shun He1, Liyan Xue3, Bas L. Weusten2,4, Sanford M. Dawsey5, David E. Fleischer6, Xiumin Qin1, Lizhou Dou1, Yong Liu1, Lu Ning3, Jacques J. Bergman2, Guiqi Wang1 1 Endoscopy, Cancer Institute and Hospital, Chinese Academy of Sciences, Beijing, China; 2Gastroenterology and Hepatology, Academic Medical Centre Amsterdam, Amsterdam, Netherlands; 3Pathology, Cancer Institute and Hospital, Chinese Academy of Sciences, Beijing, China; 4Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands; 5Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD; 6Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ Introduction: Endoscopic Resection (ER) for esophageal high-grade intraepithelial neoplasia (HGIN) or esophageal squamous cell carcinoma (ESCC) is usually performed with the ER-cap technique. This requires submucosal lifting and multiple snares for piecemeal resections and is therefore technically relatively difficult. Multi Band Mucosectomy (MBM) is an ER technique that uses a modified variceal-band ligator for piecemeal resection without submucosal lifting. In China, in certain high-risk areas where ESCC is extremely prevalent and limited endoscopic expertise is available, MBM might be a more easily applicable ER technique. Aim: We prospectively compared MBM to ER-cap for piecemeal ER of squamous neoplasia of the esophagus. Methods: Patients with HGIN or ESCC (size ⱖ2, ⱕ6 cm, max 2/3 of the circumference) and no signs of submucosal invasion or metastatic disease were included. Lesions were delineated with electrocoagulation after 1.25% Lugol staining. The patient was then randomised to MBM or ER-cap followed by piecemeal resection. Endpoints: complete endoscopic resection (ie complete removal of the lesion including all electrocoagulation markers), procedure time, costs, adverse events, absence of HGIN/ESCC at 3 months follow-up. Calculated sample size: 84 patients. Results: In 88 patients (62 male, mean age 60 yrs) ER was performed with MBM (n⫽46, 12 ESCC) or ER-cap (n⫽42, 13 ESCC). There was no difference in the size of lesions between groups (5cm vs. 5cm, p⫽NS; 42% vs. 33% of the circumference, p⫽NS). Endoscopic complete resection was achieved in all lesions. Procedure time was less with MBM (11 vs. 22 minutes, p⬍0.001), for a median of 5 vs. 4 resections (p⫽0.03). MBM resulted in smaller (18x12mm vs. 20x15mm; p⫽NS), but thicker (2200 m vs. 1700m; p⫽0.04) resection specimens. No difference in submucosal thickness was observed (900 m vs. 800 m; p⫽NS). Four patients were referred for surgery, based on the ER histology. Total costs of disposables was significantly less for MBM compared with ER-cap ($260 vs. $325, p⫽0.04).No clinically significant bleeding episodes occurred. One perforation was seen after ER-cap, which was treated conservatively. No clinically relevant stenoses were observed.At 3 months FU none of the patients demonstrated HGIN/ESCC at the resection site. Conclusion: Piecemeal ER of early esophageal squamous neoplasia with MBM is faster and cheaper compared to ER-cap. Both techniques are highly effective and safe. Given its low complexity and costs, MBM may have significant advantages over the ER-cap technique, especially in countries where ESCC is highly prevalent but endoscopic expertise and resources are limited.
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Patient, lesion and procedure characteristics Patients Age - years (SD) Gender - male : female Histology lesion pre-ER HGIN ESCC Lesion size cm % of circumference Procedure time - minutes Number of resections Size of ER specimens - mm Histology ER specimen LGIN MGIN HGIN ESCC Thickness of ER specimens (m) Submucosal thickness (m) Costs of disposables (\$) Histology ER site (3 mo FU) Squamous LGIN
MBM
ER-cap
p-value
46 60 (7) 31 : 15 34 12 5 42 11 5 18⫻12
42 59 (8) 31 : 11 29 13 5 33 22 4 20⫻15
NS NS NS NS NS NS NS ⬍0.001 0.03 NS
1 3 16 26 2200 900 260 32 8
2 2 17 21 1700 800 325 32 35
NS NS NS NS 0.04 NS 0.04 NS NS
Sa1388 Low Pressure Cryospray Ablation of High Grade Dysplasia in Barrett’s Esophagus: 2 Year Follow-up Mark H. Johnston* Gastroenterology, Lancaster Gastroenterology Inc., Lancaster, PA Background: Endoscopic ablation is currently the preferred modality for the treatment of high-grade dysplasia (HGD) in Barrett’s esophagus (BE). Objective: To assess the safety, efficacy and durability of low-pressure cryospray ablation using liquid nitrogen in the treatment of HGD in BE over a 2 year follow up period.DESIGN: Single center, nonrandomized cohort study. Technique: cryospray ablation every 8 weeks using two 20 second circumferential ablations with one minute thaws. Patients: Patients with BE and HGD. Age, length of BE, and previous ablation were not exclusion criteria Main Outcome Measurements: (1)Complete eradication of HGD, (2) complete eradication of non-dysplastic intestinal metaplasia. Results: Twenty patients with HGD in BE who refused other treatment options were treated with low pressure cryospray ablation. The mean follow-up status-post last cryospray ablation was 2 years. Nineteen of 20 patients (95%) had complete elimination of all dysplasia. Fifty-five percent had complete elimination of all nondysplastic intestinal metaplasia. Mean length of BE prior to treatment was 5 cm with a range from 11 to 1 cm. The average number treatments were 4. Complications included 2 mild esophageal strictures treated with single dilation and one bleed in a patient resuming coumadin immediately after treatment. Conclusions: Low-pressure cryospray ablation of HGD in BE using liquid nitrogen is highly effective, safe and durable over at least a two year follow-up period.
Sa1389 Endoscopic Closure of Large Mucosal Defects Post Endoscopic Submucosal Dissection (ESD) Eliminates the Need for Hospital Admission Sergey Kantsevoy*, Marianne Bitner, Lisa Turnbough, Sanjay Jagannath, Anurag Maheshwari, Paul J. Thuluvath Institute for Digestive Health and Liver Disease, Mercy Medical Center, Baltimore, MD Background: Endoscopic submucosal dissection (ESD) is gaining popularity around the World. Although it is much less invasive then laparoscopic or open surgery, patients post ESD require bowel rest and hospitalization for several days to provide optimal healing conditions for large defects created after ESD. Aim: To evaluate the use of newly developed endoscopic suturing device for closure of large mucosal defects post ESD. Methods: All procedures were performed using submucosal injection of normal saline followed by resection of the lesions utilizing ESD technique with dual knife (Olympus Medical, LTD, Tokyo, Japan). After completion of the ESD, the resulting large mucosal defects were completely closed with Overstitch endoscopic suturing device (Apollo Endosurgery, Inc, Austin, TX). All patients were discharged home post procedures with subsequent clinical and endoscopic follow-up. Results: For the last 4 months, ESD with subsequent endoscopic suturing of mucosal defect were performed in 9 patients (3 - stomach, 6 - colon). Mean age of the patients was 63.8⫾14.5 years. Average size of the lesions was 37.8⫾10.3 mm. All lesions were removed en block. Suturing with endoscopic suturing device was technically easy and required only 1 stitch (continuous suturing line) for complete closure in 7 patients. In other 2 patients mucosal defect post ESD was closed with 2 separate stitches. There were no immediate or delayed complications in any of the study patients. Conclusion: Closure of the post-ESD defects with endoscopic suturing device is technically easy, safe, and eliminates the need for hospital admission. Endoscopic closure of post-ESD defects will especially benefit patients requiring therapeutic anticoagulation.
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB187