Sa1467 Outcomes of Double Balloon Endoscopy-Assisted Direct Percutaneous Endoscopic Jejunostomy Placement

Abstracts

results, there is no need for additional fundoplication to prevent refractory reflux esophagitis with POEM.

Sa1464 Searching for the Limits: the Role of Endoscopic Resection (ER) in Submucosal Carcinoma (SMC) With Barrett’s Esophagus (BE) Gabriel Lang*1, Vani J. Konda1, Ann Koons1, Shu-Yuan Xiao2, John Hart2, Uzma D. Siddiqui1, Mark K. Ferguson3, Mitchell C. Posner3, Irving Waxman1 1 Center for Endoscopic Research and Therapeutics, The University of Chicago, Chicago, IL; 2Pathology, The University of Chicago, Chicago, IL; 3 Surgery, The University of Chicago, Chicago, IL Background: ER has emerged as standard therapy for patients with BE with intramucosal carcinoma, while esophagectomy is standard therapy for SMC. However, superficial SMC carries a lower lymph node metastasis (LNM) rate than invasion to deeper levels of submucosa. A German experience1 reported patients with sm1 lesions with well-moderately differentiated tumors and without lymphovascular invasion may benefit from ER. Aim: To assess clinical and histological characteristics of patients with SMC and evaluate the curative potential for endoscopic eradication (EE) for SMC at our institution. Methods: A chart review was performed on our prospectively collected database to identify patients status post ER with SMC. Procedure, surgery, and pathology reports were reviewed. Pathology was reviewed by 2 expert pathologists. SMC tumor invasion was characterized by thirds with sm1 as superficial, sm2 middle, and sm3 deep. Endoscopic ultrasound (EUS) was performed to rule out LNM at baseline and in follow up. EE was defined by cancer free survival after ER or if surgery was performed, subsequent surgical resection was cancer free. Results: Fifteen patients with SMC who underwent an ER were identified (mean age 69 y, M:F 4:1). Pre-ER pathology demonstrated high grade dysplasia (7) and adenocarcinoma (8). Average segment length was 6.6 cm. All patients had visible lesions with I-p lesion (1), I-s (7), II-a (5), and III (2) by Paris classification. EUS noted invasion into deep mucosa in 9 and into submucosa in 3. Three patients underwent focal ER with staging intent. One patient was managed with endoscopic submucosal dissection. One patient had been treated with ER followed by RFA. The remainder of patients underwent complete radical ER. Histology demonstrated SMC with sm1 (5), sm2 (4), and sm3 (6). Tumor differentiation was graded as well (3), moderate (8), and poor (4). Tumor extension to deep margin was noted in 6. There was presence of lymphatic invasion in 3 and vascular invasion in 3. Six patients had EE, 3 completed endoscopic therapy with cancer free survival with mean follow up of 43 months and 3 underwent surgery with no residual cancer in the resection specimen and mean cancer free survival of 34.7 months. There was no significant difference in segment length, hiatal hernia, presence of excavated lesions, or presence of submucosal invasion by ultrasound findings between those patients with successful EE and those without. The combination of sm1, G1-2, L0, and V0 was associated EE (p!0.05). All 3 patients with these criteria had EE. Conclusions: EE of SMC has potential in the subset of patients with sm1 well differentiated tumor limited to superficial submucosa without lymphovascular invasion. Long term remission rates after ER with curative intent for low risk lesions need to be established in specialized American centers. 1. Manner et al. CGH 2013

Sa1465 Factors Which Influence Variation in Endoscopic Ultrasound Fine Needle Aspiration Eric M. Nelsen*1, David Rivedal2, Deepak V. Gopal1, Patrick R. Pfau1, Mark E. Benson1 1 Gastroenterology and Hepatology, University of Wisconsin, Madison, WI; 2School of Medicine and Public Health, University of Wisconsin, Madison, WI Background: There is a paucity of research focused on factors which influence quality and uniformity in endoscopic ultrasound. Endoscopic ultrasound guided fine needle aspiration (EUS FNA) success is critical in making a tissue diagnosis; nondiagnostic cytology results lead to additional procedures and difficulty in defining treatment plans for patients. The aim of this study was to evaluate various procedural and non-procedural factors which influence EUS FNA tissue diagnosis rates. Methods: Through an institutional based quality improvement grant program, we established an endoscopic ultrasound quality database to evaluate procedural and nonprocedural factors leading to variations in endoscopic FNA outcomes. Patient demographic and clinical information, lesion type and characteristics, procedural techniques, equipment used, and personnel involved including 7 cytology technicians, 5 cytopathologists and 3 endoscopists were prospectively recorded and compared. Results: Between 1/1/13 to 8/31/13, 185 EUS FNA procedures were completed (93 pancreas mass lesions, 44 pancreas cystic lesions, 27 mediastinal/ perigastric lesions, 14 subepithelial lesions and 7 mucosal lesions) in 185 patients, mean age 62, 57 % male. There was no significant variation in the percent rates of obtaining a tissue diagnosis among the endosonographers (range 69-73%) (PZ0.81). There was a significant variation in the rates of obtaining a tissue diagnosis depending on the cytology technicians involved in the procedure (range 50-

www.giejournal.org

88%) (PZ0.02). There was a significant variation in the rates of obtaining a tissue diagnosis among the cytologists involved in the slide interpretation (range 20-81%) (PZ0.02). There was no significant difference in the rates of obtaining a tissue diagnosis between pancreas mass lesions and subepithelial lesions, 71 % and 63 % respectively (PZ0.73). There was a significant difference in the rates of obtaining a tissue diagnosis between pancreas and mediastinal/perigastric mass lesions, 71 % and 45 % respectively (PZ0.03). There was no significant difference in obtaining a tissue diagnosis between the FNA needle gauges 22 or 25, 71 % and 69 % respectively (PZ1.0). Conclusion: 1) Interestingly, the rates of obtaining a tissue diagnosis by EUS FNA were significantly influenced by the cytology technician and cytology attending involved in the procedure. 2) Variation in EUS FNA outcomes appear more related to cytology preparation and reading than endoscopic factors. 3) Endoscopic ultrasound programs should be aware of the factors which influence procedural results and uniformity in EUS FNA slide preparation and interpretation is of paramount importance to decrease variation and ensure high quality procedural outcomes.

Sa1466 Documentation of EUS Quality Indicators and Practice Patterns: a Survey of Endosonographers Ajaypal Singh*1, Uzma D. Siddiqui1, Vani J. Konda1, Ann Koons1, Harry R. Aslanian2, Irving Waxman1 1 Center for Endoscopic Research and Therapeutics, University of Chicago, Chicago, IL; 2Division of Gastroenterology, Yale University, New Haven, CT Background: Endoscopic ultrasound (EUS) with fine needle aspiration (FNA) is being increasingly used for management of gastrointestinal diseases. There is significant variability in the EUS training and practice amongst endosonographers. Aim: To evaluate the effect of volume of EUS procedures, method of training and practice setting on the techniques and complication rates of EUS-FNA. Methods: Endosonographers attending a CME course at our institution were invited to participate in this IRB approved study. The survey was administered in a paper form and consisted of 17 multiple-choice questions regarding training, practice setting, complications, and procedure related preferences. Endosonographers performing O150 EUS procedures per year were considered high volume practitioners and those with !150 annual procedures were considered low volume practitioners. Results: A total of 75 endosonographers were invited and 51 (68%) filled out the survey. Sixteen participants (31.2%) had undergone a fourth year fellowship training. Thirty participants (58.8%) were practicing in community setting while twenty-one 21 (41.2%) were in a university setting. The participants included 34 (66.7%) high volume practitioners 16 (31.4%) low volume practitioners and one participant did not answer the question. High volume practioners were more likely to have received fourth year fellowship training (15/34 vs 1/16, pZ0.007), practice in a university setting (56.9 vs 18.6%, pZ0.022), and preferred 25G needles for FNA of solid pancreatic masses (13/34 vs 1/ 16, pZ0.019). The endosonographers who had undergone formal fourth year training were more likely to document quality indicators in their procedure reports (pZ0.033). No differences were noted in the self reporting of perforation rate, perception of complication risk, practice of use of antibiotics, pre-procedure evaluation, sedation use and management of antiplatelet therapies between practitioners based on the method of EUS training, practice setting or the volume of procedures. Limitations: There is potential for recall bias, inherent to the survey based studies. Conclusion: High volume EUS practitioners were more likely to document published EUS quality indicators in their reports. In the era of healthcare change, this documentation may have implications in access to monetary support and insurance reimbursement.

Sa1467 Outcomes of Double Balloon Endoscopy-Assisted Direct Percutaneous Endoscopic Jejunostomy Placement Badr AL-Bawardy*, Emmanuel C. Gorospe, Esha Baichoo, Jeffrey A. Alexander, David H. Bruining, Elizabeth Rajan, Louis M. Wong Kee Song Mayo Clinic, Rochester, MN Background: Conventional direct percutaneous endoscopic jejunostomy (DPEJ) tube placement using pediatric or adult colonoscopes fails in approximately one third of cases, primarily due to lack of abdominal transillumination or limited instrument insertion into the jejunum. In a small pilot study, double balloon endoscopy (DBE)-assisted DPEJ placement was successful in all patients in whom attempted conventional DPEJ failed. Aim: To assess the technical success rate and adverse events related to DBE-assisted DPEJ placement in a large cohort of patients. Methods: Review of a prospectively maintained database of all patients who underwent DBE-DPEJ placement between July 2010 and November 2013 was conducted. The procedures were performed with anesthesia support, with DBE insertion up to the mid jejunum. Excessive pleating of the small bowel was avoided during reduction maneuvers. During DBE advancement, a site for DPEJ in the proximal or mid jejunum was sought, similar to conventional placement. The pull-through technique was used for feeding tube placement using a standard PEG kit. Data were abstracted for patient demographics, indications for DPEJ placement, gut anatomy, prior failed

Volume 79, No. 5S : 2014 GASTROINTESTINAL ENDOSCOPY AB223

Abstracts

procedural attempts at DPEJ, procedure duration, technical success rate, causes for failed DBE-DPEJ placement, and adverse events. Results: A total of 90 patients (55 women; mean age 55  18 years; mean BMI 22.9  6.3) underwent DBE-DPEJ placement (Table 1). Indications for DPEJ included: gastroparesis (nZ29), previous failed PEG (e.g., intrathoracic stomach, nZ16), nutritional support in altered gut anatomy unsuitable for PEG (nZ16), recurrent or high risk for aspiration (nZ13), gastric outlet obstruction (nZ11), and miscellaneous (e.g., nutritional support in setting of necrotizing pancreatitis, nZ5). Altered gut anatomy was noted in 35 (39%) patients. DBE-DPEJ was successful in all patients (nZ12) who had prior failed DPEJ attempts by extended push endoscopy or single balloon endoscopy. Mean duration of the DBE-DPEJ procedure was 31 minutes (range 10-49). DBE-DPEJ placement was successful in 83 (92%) patients. Reasons for failed DBE-DPEJ placement in 7 (8%) patients included: small bowel fixation from adhesions precluding endoscope advancement (nZ5), duodenal stenosis (nZ1), and lack of transillumination (nZ1). Post-procedural adverse events occurred in 8 (9%) patients and included: gastrointestinal bleed secondary to DPEJ site ulceration (nZ3), abdominal hematoma (nZ2), cellulitis (nZ1), kinking of the PEJ tube requiring replacement (nZ1) and gastric interposition (nZ1). Conclusion: Compared to published outcomes of DPEJ placement by conventional endoscopy, DBE-assisted DPEJ was technically successful in a high proportion of patients and with a relatively low rate of significant adverse events.

Table 1 Characteristic Indications: Gastroparesis Failed PEG Malnutrition and altered anatomy Recurrent aspiration with PEG Gastric outlet obstruction Miscellaneous (e.g. necrotizing pancreatitis) Prior failed DPEJ procedure: Extended EGD Single Balloon Enteroscopy Native Anatomy Altered Anatomy: RYGB Billroth II Whipple’s Ivor Lewis Other Duration of procedure (min) mean (range) Technical success Adverse events within 48 hours Adverse events within 1 month

Proportion ( n[90) 29 (32.2%) 16 (17.8%) 16 (17.8%) 13 (14.4%) 11 (12.2%) 5 (5.6%) 12 (13%) 9 (10%) 3 (3%) 55 (61%) 35 (39%) 16 (17.8%) 5 (5.6%) 3 (3.3%) 5 (5.6%) 6 (6.7%) 31 (10-49) 83 (92%) 3 (3.3%) 5 (5.6%)

Sa1468 Acceptability of Naso-Gastric Feeding Tubes in Nursing Homes: NYC vs. USA Eoin Slattery*, Marissa Burgermaster, Nafeesa Islam, Paul Ippolito, David S. Seres Nutrition Support, New York Presbyterian Hospital-Columbia University Medical Center, New York, NY Background: Percutaneous Endoscopic Gastrostomy (PEG) tubes are recommended for patients in whom a prolonged requirement for enteral nutrition is anticipated. However, PEG insertion is not a frivolous procedure, with 30 day mortality variably reported between 10 and 26%. There is a cohort of patients for whom naso-gastric (NG) feeding tubes may be an appropriate and viable option. Our anecdotal experience would suggest that more PEG tubes are being placed earlier in the course of a patient’s illness so as to facilitate discharge of patients to nursing homes that refuse to accept NG feeding tubes. As part of a larger policy intervention, we have endeavored to quantify the pervasiveness of this policy in New York City and compare this practice to nursing homes nationally. Methods: We performed a survey of all New York City nursing homes that accept patients for medium- to long-term care from the Milstein adult hospital at New York Presbyterian Hospital - Columbia University Medical Center. A second survey was performed from a randomized, appropriately powered national sample of nursing homes. Nursing homes were contacted during June and November 2013. A total of 127 nursing homes were identified within the bounds of New York City, and 100 were identified nationally. The directors of the nursing homes were contacted by telephone and queried on their policy with respect to acceptance of NG tubes. Results: Overall response rate in our study was 79%. The majority of nursing homes in NYC (88, 82.2% of responders) surveyed do not accept patients with NG tubes. In contrast, only 37.1% of nursing homes ouside of NYC do not accept patients with NG tubes (c2Z37.546, p!0.001). Nursing homes in NYC were 87% less likely to accept NG tubes than their counterparts in the rest of the US (ORZ0.129, 95% CI 0.06-0.27). Reasons included for not accepting NG tubes include: Department of Health policies (despite no such

AB224 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014

policy existing), concerns re: perceptions of safety (i.e. related to aspiration), and a lack of trained staff. The nursing homes in NYC that do accept NG tubes typically had qualifying requirements for acceptance. These included: only if the patient was receiving end of life care, the requirement for the tube to be removed within 2 weeks etc. Many of them had not accepted a patient with an NG tube in the last year. Conclusions: The majority of nursing homes in the New York City area do not accept NG tubes. This policy contrasts dramatically with that observed nationally. Most cite risk of aspiration as a reason for this policy (despite a lack of published evidence to support this). These findings are of concern as this policy may be leading to a significant number of PEG insertions (and all of its attendant risks) without appropriate medical indications. Efforts to address this issue are ongoing at present.

Sa1469 Prophylactic Gastrostomy Tube Insertion Prior to Treatment of Head and Neck Cancer: Clinical Outcomes From a Tertiary Centre Christopher J. Kiely*1, Joanne Benhamu2, Thomas Eade2, Venessa Pattullo1, Daniel Stiel1 1 Department of Gastroenterology, Royal North Shore Hospital, Sydney, NSW, Australia; 2Department of Radiation Oncology, Royal North Shore Hospital, Sydney, NSW, Australia Introduction: Concurrent chemoradiotherapy (CCRT) is standard of care for locally advanced head and neck cancers. Treatment related toxicities result in malnutrition and can limit CRRT dosing and scheduling. Prophylactic gastrostomy tube (GT) insertion prior to CCRT for head and neck cancers is an option to avoid malnutrition and treatment breaks, as compared to reactive nasogastric tube (NGT) insertion. Although GTs are generally well tolerated, there are limited data on their safety and utility. Aims: To evaluate the safety, efficacy and tolerability of prophylactic GT insertion for patients undergoing CCRT for head and neck cancers in a large tertiary hospital setting. Methods: Data were available for 102 patients referred for GT insertion between 2007 and 2013. Clinical, biometric, biochemical and histological data were collected prospectively. Results: See Table 1 for demographic data. Eighty-four patients (82%) underwent endoscopic GT insertion, thirteen (13%) surgical and five (5%) radiological insertion. Nine patients were deemed unsuitable at endoscopy, requiring a second procedure. Eighty-eight patients received prophylactic antibiotics at the time of GT insertion. Twenty-four patients developed minor gastrostomy site infections requiring short courses of antibiotics. Non-obese patients (BMI!30kg/m2) were significantly less likely to develop infection (OR 0.143 (95%CI 0.043-0.472), pZ0.001). Four patients experienced significant pain in the days following insertion, one had GT site external leakage, and one radiological GT patient experienced balloon deflation and dislodgement. Seven patients required brief unplanned readmission within 7 days of GT insertion due to pain or anxiety. Surgical insertion was significantly associated with readmission within seven days compared with endoscopic insertion (23.1%% vs 4.8%% respectively, p!0.05). One patient developed significant aspiration pneumonitis following endoscopic attempt. Ninety-nine patients (97%) used their GT during treatment, and the GT remained in-situ for mean 14260 days. Despite GT use, weight loss was recorded in all patients. Mean weight loss was 8.65.2 kg. Mean weight increase from lowest recorded weight to time of GT removal was 1.321.7 kg. There were no documented cases of seeding of tumour cells to the gastrostomy site. During an overall median follow up of 19 months (interquartile range 12-32), 19 patients died, with death occurring a median 15 months (IQR 6-25) post GT insertion. Conclusion: Prophylactic gastrostomy tube insertion is generally safe and well tolerated by patients. Serious complications appear to be uncommon. Surgical insertion appears to be associated with an increased rate of readmission within seven days, perhaps related to the more invasive nature of this procedure. Obese patients had significantly higher rates of GT site infections. Table 1. Baseline characteristics of the prophylactic gastrostomy tube

cohort Number of patients Age (years) Gender (f:m) Index Body-mass index (kg/m2) Pre-treatment weight (kg) Lowest recorded weight (kg) Cigarette smoking history Never smoked Current smoker Previous smoker Diabetes Tumour location Nasopharynx Oropharynx Hypopharynx ECOG* 0 1 O1 Method of insertion Endoscopic Radiological Surgical

102 59  standard deviation 10.7 20:82 26.1 4.6 79.6 16.8 70.8 14 32 14 54 9 5 82 14 76 26 0 84 5 13

*ECOGZEastern Cooperative Oncology Group performance status

www.giejournal.org