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Sa1548 Temporary Self-Expanding Plastic Stent Placement or Biodegradable Stent Placement for Refractory Benign Esophageal Strictures: A Comparison
Abstracts
Sa1547 The Efficacy of Cryospray Ablation Therapy in Eradicating Dysplastic Barrett’s Esophagus Jayaprakash Sreenarasimhaiah, Deepak Agrawal, Luis F. Lara Medicine/Gastroenterology, University of Texas Southwestern Medical Center, Dallas, TX Background: Dysplastic Barrett’s esophagus has historically been treated by surgery. However, endoscopic therapy has recently become well-established as a minimally-invasive alternative. One of the newest modalities available is cryospray ablation therapy. Aims: To determine if cryospray ablation therapy is a safe and effective means for ablation of dysplastic Barrett’s esophagus. Methods: All consecutive patients who underwent cryospray ablation therapy for dysplastic Barrett’s esophagus over a 24-month period were included. Patients were treated with liquid nitrogen (CSA Medical) for high-grade dysplasia (HGD) or persistent low-grade dysplasia (LGD, noted on two endoscopies at 6-month intervals). Nodules were treated with a combination of endoscopic mucosal resection (EMR) and cryospray ablation therapy. Endoscopic ultrasound was used to confirm that disease was confined to the esophageal mucosa in high-grade dysplastic or nodular carcinoma cases. Results: The study group included 26 patients (mean age 67.1 years; 19 male and 7 female) who underwent a total of 57 sessions of cryospray ablation therapy. The mean number of sessions was 2.2 per patient with a mean length of 5.7cm. HGD was seen in 14 patients; intramucosal cancer was noted in 3 patients; persistent LGD was present in 9 patients. Three patients were lost to follow-up due to insurance or co-morbid illness. Of 23 patients who completed therapy, 20 (87%) had no visible Barrett’s mucosa. In 3 /23 (13%), histologic features of Barrett’s mucosa was noted without dysplasia. In all 3 patients with intramucosal nodular carcinoma, endoscopic therapy was successful with no findings at 6 months - cryospray alone (1), EMR prior to cryotherapy (1), and EMR following cryotherapy (1). No patients required narcotics or hospitalization following the procedure. In 57 sessions of cryotherapy, 3 (5%) strictures developed which were treated successfully with endoscopic balloon dilation. Conclusions: Cryospray ablation therapy is effective in the complete eradication of Barrett’s with high-grade dysplasia, low-grade dysplasia, and intramucosal (T1) carcinoma. This therapy can be successfully combined with EMR therapy. The low stricture rate and lack of significant post-procedure pain demonstrate the safety and attractiveness of this modality.
Sa1548 Temporary Self-Expanding Plastic Stent Placement or Biodegradable Stent Placement for Refractory Benign Esophageal Strictures: A Comparison Petra G. Van Boeckel, Frank P. Vleggaar, Peter D. Siersema Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands Background: Benign esophageal strictures refractory to standard dilation therapy are a challenging problem. Temporary self-expanding plastic stent (SEPS) placement is increasingly being used in an effort to prolong the dilation effect in patients with refractory benign esophageal strictures (RBES). Recently, biodegradable (BD) stents have been introduced as an alternative stent design for treatment of RBES. Aim: To determine clinical effectiveness and safety of SEPS or BD stent placement for the treatment of RBES. Methods: Two groups of consecutive patients with RBES who underwent temporary SEPS placement for a period of 6 weeks or BD stent placement were included. Data were collected with respect to technical and clinical success, complications, recurrent dysphagia and number of reinterventions. Results: In total, 38 patients with dysphagia from RBES were treated with placement of a SEPS (n⫽20) or BD stent (n⫽18). The etiology of the strictures was peptic (SEPS 1, BD stent 6), anastomotic (SEPS 8, BD stent 5), post-radiation (SEPS 5, BD stent 2), post-caustic (SEPS 4, BD stent 2) or another cause (SEPS 2, BD stent 3) (p⫽0.18). Stent placement was technically successful in 19 (95%) patients with a SEPS, and in 16 (89%) with a BD stent (p⫽ 0.49). SEPS removal was performed in 16/19 (84%) patients with successful SEPS placement. Six of 20 (30%) patients with SEPS were dysphagia-free after a median follow-up of 385 days (range 77-924), 10 (50%) developed recurrent dysphagia and in 3 (15%) the SEPS was not removed. Six (33%) of 18 patients with a BD stent were dysphagia-free after a median follow-up of 166 days (range 21-559) (p⫽0.83 compared to SEPS) and 12 (67%) had recurrent dysphagia. Major complications occurred in 2 (10%) patients with a SEPS (hemorrhage [n⫽1] and perforation [n⫽1]) and in 4 (22%) with a BD stent (hemorrhage [n⫽2], severe retrosternal pain [n⫽2]) (p⫽0.30). Reinterventions were less frequently performed after BD stent placement than after SEPS placement (15 (mean: 0.8 ⫹/- 0.6 per stent placed) vs. 21 (mean: 1.3 ⫹/- 0.4 per stent placed), respectively, p⫽0.03). There was no stent-related mortality. Conclusion: Both SEPS and BD stent placement achieve long-term relief of dysphagia without further interventions in a third of patients with RBES. BD stents have the advantage over SEPS that fewer procedures are required. Although stent placement is an interesting treatment option in patients with RBES, the ideal strategy still needs to be defined.
Sa1549 Endoscopic Ultrasonography in Preoperative Staging of Cancer in Esophagus and Cardia and the Impact of Neoadjuvant Therapy on Its Reliability Ludek Hrdlicka1, Radan Keil1, Tomas Harustiak2, Markéta Rozneˇtinská1 1 Department of Internal Medicine, Faculty Hospital Motol, Praha 5, Czech Republic; 23-rd Surgical Department, Faculty Hospital Motol, Prague 5, Czech Republic Introduction: Endoscopic ultrasonography (EUS) is generally accepted as the most contributable method in local staging of esophageal cancer. It has a greatest impact on indication of primary surgical therapy or neoadjuvant therapy in potentially resectable processes. After neoadjuvant therapy is usually an endosonographic restaging performed. Because of structural tissue changes after radio and chemotherapy resulting in worse conditions for ultrasonography the accuracy of EUS can be decreased, that is why we designed comparative study with surgical finding and histopathology as a gold standard. Methods: We followed prospectively preoperative examinations of patients with histologically confirmed cancer in esophagus or cardia in whom a staging with EUS was performed (Olympus MH-908 a JF-UM20) in our department during the year 2009. Results were compared with surgical findings and definite TNM classification. In patients treated with neoadjuvant therapy restaging was performed after the end of treatment. Then we compared EUS results of patients with and without neoadjuvant therapy. In 2009 we examined in our department 96 patients with the above diagnosis. In our sample we included 49 patients in whom we performed a complete preoperative staging and underwent radical surgery with possibility of definitive histopathological classification of TN stage. Results: From 49 patients in our sample 39 patients had adenocarcinoma and 10 spinocellular carcinoma. Stage T1 was preoperatively determined in 6 patients (4 treated with endoscopic resection and 2 treated surgically), stage T2 in 11 patients, T3 in 27 patients an T4 in 5 patients of our sample. 33 patients underwent neoadjuvant therapy and subsequent restaging Sensitivity and specificity in preoperative EUS were in stage T1 100%, in stage T2 sensitivity was 77% and specificity 90%, in T3 sensitivity 86% and specificity 75%, in stage T4 sensitivity 80% and specificity 75%. Comparison of sensitivity and specificity in T staging in patients without neoadjuvant therapy (16 patients) and after neoadjuvant radio-chemotherapy (33 patients) is 88% vs. 81% and 95% vs. 75%. Sensitivity for regional mediastinal lymph nodes was 65%, specificity 75%, for celiac lymph nodes 60% sensitivity and 95% specificity. Conclusion: In our study preoperative EUS staging was compared with surgical finding and definitive histopathological classification of TN stage. Radial EUS provided useful and comparatively reliable information about local stage of the disease in decision about the treatment options in patients with cancer in oesophagus or cardia. We found high sensitivity and specificity in T staging, the yield in N staging was lower. Neoadjuvant radio-chemotherapy significantly decreased reliability of EUS T staging in preoperative restaging of cancer in oesophagus and cardia.
Sa1550 Lower Recurrence Rate With ESD vs. EMR for the Curative Treatment of Esophageal Superficial Squamous Cell Carcinoma Pierre H. Deprez1, Romain Altwegg1, Anne Jouret- Mourin2, Christine Sempoux2, Tarik Aouattah1, Ralph C. Yeung1, Hubert Piessevaux1 1 Gastroenterology, Cliniques universitaires Saint-Luc, Brussels, Belgium; 2 Pathology, Cliniques universitaires Saint-Luc, Brussels, Belgium Introduction: The role of endoscopic submucosal dissection (ESD) in squamous cell carcinoma is still discussed in Europe with many centres proposing piecemeal EMR, although many studies from Japan showed the importance of R0 that can only be achieved by en-bloc resection with free deep and lateral margins. The aim of our study was to analyse our experience with ESD and to compare these with historical results of piecemeal EMR. Patients and Methods: EMR and ESD have been performed for superficial squamous cell cancer since Dec 1999 and Jan 2007, respectively. Follow-up was done at 2, 6, 12 months after resection, then annually. Results: are expressed as median and range and statistical analysis done by Mann Whitney U-test and chi square. Results: 60 patients (30 pts by EMR since Dec 1999 and 30 pts by ESD since Jan 2007). No significant difference could be seen in terms of age, sex, Paris classification, tumor localisation, and R0 resection (Table 1). Complications rate was similar: no perforation, no early or delayed bleeding, 17-20% strictures, with 4 pts with severe fibrosis (type 3) due to previous EMR, eosinophilic esophagitis, radiotherapy or surgery. In the ESD group, 6 lesions were HGIN, 3 pT1m2, 11 pT1m3, 8 pT1sm1, and 2 pT1sm2. In the EMR group, 16 lesions were HGIN, 4 pT1m2, 5 pT1m3, 3 pT1sm1, 1 pT1sm2 and 1 T2. Recurrence rate was significantly lower with ESD (1 case [3%] vs. 8 [26%] with EMR, p ⫽ 0,01), and recurrence was observed after a median follow-up period of 11,5 m [3-53]. Eight pts and 7 received adjuvant therapy in the ESD and EMR groups, respectively. Conclusions: ESD can be safely performed for the curative treatment of mucosal esophageal squamous cancer, with low rates of bleeding and perforation, higher
AB204 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
Sa1547 The Efficacy of Cryospray Ablation Therapy in Eradicating Dysplastic Barrett’s Esophagus Jayaprakash Sreenarasimhaiah, Deepak Agrawal, Luis F. Lara Medicine/Gastroenterology, University of Texas Southwestern Medical Center, Dallas, TX Background: Dysplastic Barrett’s esophagus has historically been treated by surgery. However, endoscopic therapy has recently become well-established as a minimally-invasive alternative. One of the newest modalities available is cryospray ablation therapy. Aims: To determine if cryospray ablation therapy is a safe and effective means for ablation of dysplastic Barrett’s esophagus. Methods: All consecutive patients who underwent cryospray ablation therapy for dysplastic Barrett’s esophagus over a 24-month period were included. Patients were treated with liquid nitrogen (CSA Medical) for high-grade dysplasia (HGD) or persistent low-grade dysplasia (LGD, noted on two endoscopies at 6-month intervals). Nodules were treated with a combination of endoscopic mucosal resection (EMR) and cryospray ablation therapy. Endoscopic ultrasound was used to confirm that disease was confined to the esophageal mucosa in high-grade dysplastic or nodular carcinoma cases. Results: The study group included 26 patients (mean age 67.1 years; 19 male and 7 female) who underwent a total of 57 sessions of cryospray ablation therapy. The mean number of sessions was 2.2 per patient with a mean length of 5.7cm. HGD was seen in 14 patients; intramucosal cancer was noted in 3 patients; persistent LGD was present in 9 patients. Three patients were lost to follow-up due to insurance or co-morbid illness. Of 23 patients who completed therapy, 20 (87%) had no visible Barrett’s mucosa. In 3 /23 (13%), histologic features of Barrett’s mucosa was noted without dysplasia. In all 3 patients with intramucosal nodular carcinoma, endoscopic therapy was successful with no findings at 6 months - cryospray alone (1), EMR prior to cryotherapy (1), and EMR following cryotherapy (1). No patients required narcotics or hospitalization following the procedure. In 57 sessions of cryotherapy, 3 (5%) strictures developed which were treated successfully with endoscopic balloon dilation. Conclusions: Cryospray ablation therapy is effective in the complete eradication of Barrett’s with high-grade dysplasia, low-grade dysplasia, and intramucosal (T1) carcinoma. This therapy can be successfully combined with EMR therapy. The low stricture rate and lack of significant post-procedure pain demonstrate the safety and attractiveness of this modality.
Sa1548 Temporary Self-Expanding Plastic Stent Placement or Biodegradable Stent Placement for Refractory Benign Esophageal Strictures: A Comparison Petra G. Van Boeckel, Frank P. Vleggaar, Peter D. Siersema Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, Netherlands Background: Benign esophageal strictures refractory to standard dilation therapy are a challenging problem. Temporary self-expanding plastic stent (SEPS) placement is increasingly being used in an effort to prolong the dilation effect in patients with refractory benign esophageal strictures (RBES). Recently, biodegradable (BD) stents have been introduced as an alternative stent design for treatment of RBES. Aim: To determine clinical effectiveness and safety of SEPS or BD stent placement for the treatment of RBES. Methods: Two groups of consecutive patients with RBES who underwent temporary SEPS placement for a period of 6 weeks or BD stent placement were included. Data were collected with respect to technical and clinical success, complications, recurrent dysphagia and number of reinterventions. Results: In total, 38 patients with dysphagia from RBES were treated with placement of a SEPS (n⫽20) or BD stent (n⫽18). The etiology of the strictures was peptic (SEPS 1, BD stent 6), anastomotic (SEPS 8, BD stent 5), post-radiation (SEPS 5, BD stent 2), post-caustic (SEPS 4, BD stent 2) or another cause (SEPS 2, BD stent 3) (p⫽0.18). Stent placement was technically successful in 19 (95%) patients with a SEPS, and in 16 (89%) with a BD stent (p⫽ 0.49). SEPS removal was performed in 16/19 (84%) patients with successful SEPS placement. Six of 20 (30%) patients with SEPS were dysphagia-free after a median follow-up of 385 days (range 77-924), 10 (50%) developed recurrent dysphagia and in 3 (15%) the SEPS was not removed. Six (33%) of 18 patients with a BD stent were dysphagia-free after a median follow-up of 166 days (range 21-559) (p⫽0.83 compared to SEPS) and 12 (67%) had recurrent dysphagia. Major complications occurred in 2 (10%) patients with a SEPS (hemorrhage [n⫽1] and perforation [n⫽1]) and in 4 (22%) with a BD stent (hemorrhage [n⫽2], severe retrosternal pain [n⫽2]) (p⫽0.30). Reinterventions were less frequently performed after BD stent placement than after SEPS placement (15 (mean: 0.8 ⫹/- 0.6 per stent placed) vs. 21 (mean: 1.3 ⫹/- 0.4 per stent placed), respectively, p⫽0.03). There was no stent-related mortality. Conclusion: Both SEPS and BD stent placement achieve long-term relief of dysphagia without further interventions in a third of patients with RBES. BD stents have the advantage over SEPS that fewer procedures are required. Although stent placement is an interesting treatment option in patients with RBES, the ideal strategy still needs to be defined.
Sa1549 Endoscopic Ultrasonography in Preoperative Staging of Cancer in Esophagus and Cardia and the Impact of Neoadjuvant Therapy on Its Reliability Ludek Hrdlicka1, Radan Keil1, Tomas Harustiak2, Markéta Rozneˇtinská1 1 Department of Internal Medicine, Faculty Hospital Motol, Praha 5, Czech Republic; 23-rd Surgical Department, Faculty Hospital Motol, Prague 5, Czech Republic Introduction: Endoscopic ultrasonography (EUS) is generally accepted as the most contributable method in local staging of esophageal cancer. It has a greatest impact on indication of primary surgical therapy or neoadjuvant therapy in potentially resectable processes. After neoadjuvant therapy is usually an endosonographic restaging performed. Because of structural tissue changes after radio and chemotherapy resulting in worse conditions for ultrasonography the accuracy of EUS can be decreased, that is why we designed comparative study with surgical finding and histopathology as a gold standard. Methods: We followed prospectively preoperative examinations of patients with histologically confirmed cancer in esophagus or cardia in whom a staging with EUS was performed (Olympus MH-908 a JF-UM20) in our department during the year 2009. Results were compared with surgical findings and definite TNM classification. In patients treated with neoadjuvant therapy restaging was performed after the end of treatment. Then we compared EUS results of patients with and without neoadjuvant therapy. In 2009 we examined in our department 96 patients with the above diagnosis. In our sample we included 49 patients in whom we performed a complete preoperative staging and underwent radical surgery with possibility of definitive histopathological classification of TN stage. Results: From 49 patients in our sample 39 patients had adenocarcinoma and 10 spinocellular carcinoma. Stage T1 was preoperatively determined in 6 patients (4 treated with endoscopic resection and 2 treated surgically), stage T2 in 11 patients, T3 in 27 patients an T4 in 5 patients of our sample. 33 patients underwent neoadjuvant therapy and subsequent restaging Sensitivity and specificity in preoperative EUS were in stage T1 100%, in stage T2 sensitivity was 77% and specificity 90%, in T3 sensitivity 86% and specificity 75%, in stage T4 sensitivity 80% and specificity 75%. Comparison of sensitivity and specificity in T staging in patients without neoadjuvant therapy (16 patients) and after neoadjuvant radio-chemotherapy (33 patients) is 88% vs. 81% and 95% vs. 75%. Sensitivity for regional mediastinal lymph nodes was 65%, specificity 75%, for celiac lymph nodes 60% sensitivity and 95% specificity. Conclusion: In our study preoperative EUS staging was compared with surgical finding and definitive histopathological classification of TN stage. Radial EUS provided useful and comparatively reliable information about local stage of the disease in decision about the treatment options in patients with cancer in oesophagus or cardia. We found high sensitivity and specificity in T staging, the yield in N staging was lower. Neoadjuvant radio-chemotherapy significantly decreased reliability of EUS T staging in preoperative restaging of cancer in oesophagus and cardia.
Sa1550 Lower Recurrence Rate With ESD vs. EMR for the Curative Treatment of Esophageal Superficial Squamous Cell Carcinoma Pierre H. Deprez1, Romain Altwegg1, Anne Jouret- Mourin2, Christine Sempoux2, Tarik Aouattah1, Ralph C. Yeung1, Hubert Piessevaux1 1 Gastroenterology, Cliniques universitaires Saint-Luc, Brussels, Belgium; 2 Pathology, Cliniques universitaires Saint-Luc, Brussels, Belgium Introduction: The role of endoscopic submucosal dissection (ESD) in squamous cell carcinoma is still discussed in Europe with many centres proposing piecemeal EMR, although many studies from Japan showed the importance of R0 that can only be achieved by en-bloc resection with free deep and lateral margins. The aim of our study was to analyse our experience with ESD and to compare these with historical results of piecemeal EMR. Patients and Methods: EMR and ESD have been performed for superficial squamous cell cancer since Dec 1999 and Jan 2007, respectively. Follow-up was done at 2, 6, 12 months after resection, then annually. Results: are expressed as median and range and statistical analysis done by Mann Whitney U-test and chi square. Results: 60 patients (30 pts by EMR since Dec 1999 and 30 pts by ESD since Jan 2007). No significant difference could be seen in terms of age, sex, Paris classification, tumor localisation, and R0 resection (Table 1). Complications rate was similar: no perforation, no early or delayed bleeding, 17-20% strictures, with 4 pts with severe fibrosis (type 3) due to previous EMR, eosinophilic esophagitis, radiotherapy or surgery. In the ESD group, 6 lesions were HGIN, 3 pT1m2, 11 pT1m3, 8 pT1sm1, and 2 pT1sm2. In the EMR group, 16 lesions were HGIN, 4 pT1m2, 5 pT1m3, 3 pT1sm1, 1 pT1sm2 and 1 T2. Recurrence rate was significantly lower with ESD (1 case [3%] vs. 8 [26%] with EMR, p ⫽ 0,01), and recurrence was observed after a median follow-up period of 11,5 m [3-53]. Eight pts and 7 received adjuvant therapy in the ESD and EMR groups, respectively. Conclusions: ESD can be safely performed for the curative treatment of mucosal esophageal squamous cancer, with low rates of bleeding and perforation, higher
AB204 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org