- Email: [email protected]
Sa1637 Direct Percutaneous Endoscopic Jejunostomy: A Retrospective Analysis of Indications, Success and Outcome
Abstracts
Sa1633 Endoscopic Treatment of Watermelon Stomach: Argon Plasma Coagulation Versus Band Ligation Ladislava Sebkova, Stefano Rodino’, Teresa D’Amico, Natale Saccà Gastroenterology Unit, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy Background: Watermelon stomach is well-known cause of gastrointestinal bleeding and anemia. Argon plasma coagulation (APC) was demonstrated safe and effective for the treatment of watermelon stomach. Recent data suggested the possibility of treatment with endoscopic band ligation (EBL). Objective: Retrospective study designed to compare APC versus EBL treatment for watermelon stomach treatment valuating number of treatments, days of hospitalization and transfusion requirement. Patients: In the study were included 15 patients (9 females, median age 68 years, range 32-87) treated for watermelon stomach at our endoscopic unit between January 2007 until March 2009, Patients were followed-up for 6 months after eradication of antral vascular ectasia. Results: Patients treated with APC were 10 and with EBL were 5. Both methods were successful for eradication of antral vascular ectasia. Significant differences were found in number of treatment session (1,6 in EBL vs 4,6 in APC group), greater decrease in transfusion requirement (2,8 units in EBL vs 6,8 units in APC group) and greater decrease in days of hospitalization during the treatment and the follow-up (4,2 days of EBL vs 8,6 days in APC group). Before treatment no significant differences in the demographics, clinical presentation and mean hemoglobin values were observed between both groups. Conclusion: APC and EBL treatment of watermelon stomach are both effective and safe. Our initial experience suggests superior results for EBL reducing mainly number of treatment session to obtain complete eradication of antral vascular ectasia. In our opinion other advantages (reduced transfusion requirement and days of hospitalization) are secondary to the faster eradication of antral vascular ectasia due to important reduction of treatment session. Unlike APC, EBL can be applied all over the antrum in a single session, and because it’s simple method that does not require any expensive equipment, accessories, or advanced training. Other, probably multicenter studies, are necessary to show clearly advantages of single method.
Sa1634 Utilization of the Critical Care Unit for Emergency Endoscopic Treatment At Night or Weekends Improved the Mortality Rate for Patients With Non-Variceal Upper Gastrointestinal Bleeding Masao Toki, Yasuharu Yamaguchi, Kenji Nakamura, Shin’Ichi Takahashi The 3rd Dept. of Med, Kyorin Univ. School of Med., Tokyo, Japan [Aims] Our hospital is one of the medical facilities playing a crucial role in critical care in Japan, annually accepting about 35,000 emergency patients. On a daily basis, staff insufficiency is marked for emergency endoscopic treatment, especially at night and weekends. Thus, we investigated the current status of emergency endoscopic treatment at night and weekends in our hospital and explored valid means of improving the mortality for patients received emergency endoscopic treatment. [Methods] ⬍Study 1⬎ The study involved 2039 patients having undergone emergency endoscopic treatment between January 2005 and July 2007. Among these patients, 6 died. We analyzed the factors of these 6 fatal patients in detail. ⬍Study 2⬎ From results of Study 1, we adopted the strategy that the Critical Care Unit would be utilized for emergency endoscopy at night and weekends for both inpatients and outpatients with non-variceal upper gastrointestinal bleeding (NUGIB). This strategy was adopted for the following reasons: (1) The Critical Care Unit is staffed adequately even at night and weekends, making it easy to secure manpower needed for treatment. (2) Sudden changes in the patients condition can be smoothly dealt with under support by nurses experienced with critical care. (3) Help by physicians specializing in critical care is available in case of sudden changes of the patient’s condition. (4) The endoscopist can concentrate on hemostasis if adequate manpower is available. (5) The unit has an angiography room and an operating room. Thus, it is smooth to transfer to the 2nd line treatment such as angiography or surgery for patients with endoscopic refractory NUGIB. We investigated whether utilization of the Critical Care Unit for emergency endoscopic treatment at night or weekends improve the mortality rate for patients with NUGIB. [Results] ⬍Study 1⬎ The 6 patients who died were composed of 2 patients with gastric ulcer, 1 with gastric cancer, 1 with duodenal ulcer and 2 with other diseases. All of these 6 patients were carried to our hospital at night or weekends. Five of them underwent endoscopy in the insufficiently-staffed endoscopy room. ⬍Study 2⬎ During the period from August 2007 to October 2010, 146 patients underwent emergency endoscopy at night or weekends. No death was recorded among the patients for whom the Critical Care Unit was utilized for emergency endoscopic treatment at night or weekends. Smooth transfer to angiography (9 cases) and operation (3 cases) was possible during management of the 146 cases. Three patients suffered cardiac or respiratory arrest, but resuscitation was successful in all these cases. [Conclusion] Utilization of the Critical Care Center for emergency upper endoscopic treatment at night or weekends was shown to be beneficial for patient management and is expected to improve the mortality rate.
Sa1635 The Adequate Number of Biopsy Specimen in an Era of the HighQuality for the Diagnosis of Malignant or Premalignant Gastric Lesions: Preliminary Results of a Prospective Observational Study Hyoun Woo Kang, Jun Kyu Lee, Jae Hak Kim, Moon Soo Koh, Jin Ho Lee Internal medicine, Dongguk University College of Medicine, Goyang, Republic of Korea Background: Getting six pieces of biopsy specimen around a lesion is the most widely-used method when gastric malignancy is suspected on the esophagogastrodudenoscopic examination. This practice originates from one Japanese study conducted in 1970’s. However, endoscopists are being faced with some changes which force them to reconsideration this old principle. The resolution of the endoscope has improved dramatically and even the magnification to identify individual lining cells is possible nowadays. Endoscopists can target a lesion more accurately with this innovation. In addition, patients taking anti-platelet agents or warfarin have increased markedly due to expanding incidences of cardiovascular disease and stroke. Performing biopsy in these patients might cause significant bleeding, and the chances increase when more pieces of specimen are bitten. Aim: The authors intended to reassess the optimal numbers of biopsy specimen for the diagnosis of gastric cancer in an era of the high-quality endoscopy. Methods: A total 84 gastric lesions which were endoscopically-suspected by experienced endoscopists for having malignant or premalignant were prospectively included at the Dongguk University Ilsan Hospital from Jan 2008 to Dec 2009. Six pieces of biopsy specimen per lesion were gathered separately in order and analyzed pathologically. Results: Sixty were diagnosed as malignant or premalignant gastric lesions, and 5, 32, and 25 were finally diagnosed as gastric adenoma, early gastric cancer, or advanced gastric cancer (AGC), respectively. Positive results were obtained in 47 (78.3%), 53 (88.3%), 54 (90%), 59 (98.3%), 59 (98.3%) and 60 (100%) out of 60 lesions on the 1st, 2nd, 3rd, 4th, 5th and 6th specimen cumulatively. Five out of 6 cases, which showed the false negative results upto the 4th specimen were finally diagnosed as AGC, Borrmann type 4. No significant bleeding happened during the study period. Conclusions: Taking four pieces of biopsy specimen is sufficient when a malignant or premalignant gastric lesion is suspected endoscopically with an exception of AGC, Borrmann type 4.
Sa1636 Buried Bumper Syndrome: Prevalence and Endoscopic Management Marianna Arvanitakis1,2, Ziad El Ali1, Asuncion Ballarin2, Jacques M. E. Deviere1, Olivier Le Moine1, Andre M. Van Gossum1,2 1 Gastroenterology, Erasme University Hospital, Brussels, Belgium; 2 Nutrition Team, Erasme University Hospital, Brussels, Belgium Rationale: Buried bumper syndrome (BBS) is a rare long-term complication of percutaneous endoscopic gastrostomy (PEG) and consists of a progressive impaction of the inner bumper of the tube in the gastric wall, resulting from excessive traction and overtightening of the outer flange. The aim of our study was to report our own experience with patients with BBS, focusing on their endoscopic management. Methods: Medical records of 879 patients having undergone PEG insertion (2002-2009) were retrospectively reviewed. Patients presenting with BBS during their follow-up were noted, including clinical data and endoscopic management. Results: Eight patients (8/879; 0.9%) developed BBS, which was confirmed during gastroscopy. The mean time between PEG insertion and the BBS diagnosis was 36 ⫾ 31 months. A critically-ill patient died shortly after the diagnosis, and in two patients BBS was managed surgically. The needle-knife excision technique was used to remove the buried bumper in 5 patients. A flexible guide wire was inserted through the internal orifice of the PEG to define anatomical settings. Next, cruciform excisions of the mucosa were performed with the needle-knife starting at the center of the mucosal dome covering the internal bumper, and reaching its edges. Subsequently, the bumper was extruded and completely extracted, through the gastric tract, with a standard rat tooth forceps. A new replacement balloon gastrostomy was inserted in the PEG orifice during the same procedure. All patients received antibiotics during the procedure. Length of stay related to BBS treatment was 6.7 ⫾ 4.2 days. No complications were noted. Conclusions: Buried bumper syndrome is a rare longterm PEG complication. It can be prevented by avoiding over traction of the outer flange and assuring tube mobilization during follow-up. A useful and safe technique to treat BBS is mucosal excision with the needle-knife.
Sa1637 Direct Percutaneous Endoscopic Jejunostomy: A Retrospective Analysis of Indications, Success and Outcome Marianna Arvanitakis1,2, Asuncion Ballarin2, Jacques M. E. Deviere1, Olivier Le Moine1, Andre M. Van Gossum1,2 1 Gastroenterology, Erasme University Hospital, Brussels, Belgium; 2 Nutrition Team, Erasme University Hospital, Brussels, Belgium Rationale: Percutaneous access to the jejunum can provide enteral feeding if the gastric route is not possible. The aim of this study was to evaluate indications, success rate, short- and long-term complications and outcome in patients in
AB230 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
Abstracts
whom a percutaneous endoscopic jejunostomy (PEJ) was performed. Methods: Clinical data concerning patients in whom a PEJ was scheduled between 1/2006 and 1/2010 were retrospectively collected and analyzed. Results: Twenty-two patients were included. In 4 patients, the procedure was unsuccessful, due to lack of translumination; therefore the success rate was 81%. In 3 of these patients, a percutaneous endoscopic gastrostomy with a jejunal extension was placed and one patient underwent surgery. The remaining 18 patients (10 men, 8 women) who underwent successful PEJ placement had a median age of 57 years (22-79) and a body mass index of 18,5 (13-33). Regarding underlying disease, 5 patients (27.8%) had previous lung transplantation and 7 (38.9%) had gastrectomy. Indications for jejunal access were as follows: gastroparesis (n⫽5, 27.8%), gastrectomy (n⫽7, 38.9%) and severe reflux (n⫽6, 33.3%). Eight patients had previous nasogastric (n⫽2) or nasojejunal (n⫽6) tube. An enteroscope was used in 11 patients, whereas a gastroscope was used in 6 and a pediatric colonoscope in 1 patient. Eighteen french tubes with an internal bumper were used in all patients. No patient presented with short-term complications. Six patients had long-term complications (tube migration and local infection). Seven patients required a second procedure during follow-up. Enteral feeding was well tolerated in 13 patients (72.2%) and weight gain was observed in 6 (33.3%). Total median length of jejunal feeding was 6 months (1-36). Conclusions: PEJ is a useful endoscopic alternative for providing enteral nutrition when gastrostomy is not possible. Frequent indications in our series include previous gastrectomy and gastroparesis following lung transplantation.
Sa1638 Risk Factors for Local Recurrence After En Bloc Resection of Endoscopic Submucosal Dissection for the Early Gastric Cancer Treatment Eunsoo Kim, Kwangbum Cho, Kyung Sik Park Internal medicine, Keimyung University School of Medicine, Daegu, Republic of Korea Backgrounds/Aim: Endoscopic submucosal dissection (ESD) has been accepted as an alternative method to surgery for the treatment of early gastric cancer (EGC). Piecemeal resection has been reported to be associated with the local recurrence after ESD. However, there is no study evaluating local recurrence after en bloc resection of ESD. The aim of this study was to assess risk factors for local recurrence after en bloc resection of ESD for the treatment of EGC. Methods: From April 2003 to May 2010, patients with EGC treated by ESD and followed up for at least 6 months were eligible for this study and their medical records were evaluated retrospectively. We excluded the lesions removed by the way of a piecemeal resection and involved in the deep margin pathologically. The lesions with lateral safety margin less than 1 mm was considered as the inadequate group. Results: Among 1,215 gastric epithelial lesions in 1,121 patients, 415 EGC lesions in 401 patients were included (median age 66 (32-87), male 291, median follow-up month 14.8). The overall recurrence rate was 8.7% (36/415) and EGC with ill defined margin was identified as a significant independent risk factor for local recurrence in the multivariate analysis (OR 2.369, 95% CI 1.101-5.098, p⫽0.027). The cumulative recurrence was more observed in the inadequate group (lateral safety margin ⬍1 mm) through Kaplan-Meier analysis (p⫽0.019). Multivariate predictive factor for inadequate lateral safety margin was the tumor location (upper third vs. lower third, p⬍0.001). Conclusion: Aside from achievement of en bloc resection during ESD, efforts should be made to identify the clear lateral margin of tumor for avoiding local recurrence. Endoscopists should pay attention to obtain an adequate tumor safety margin especially in upper-located gastric tumor lesions.
Sa1639 Prediction Score for Marginal Ulcer Formation After Roux-en-Y Gastric Bypass Barham K. Abu Dayyeh1,2, Pichamol Jirapinyo1, Dan E. Azagury3, Christopher C. Thompson1 1 Division of Gastroenterology, Brigham & Women’s Hospital, Boston, MA; 2Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA; 3Bariatric/Minimally Invasive Surgery, Brigham & Women’s Hospital, Boston, MA Background & Aims: Marginal ulceration (MU) is a frequent complication after Roux-en-Y gastric bypass (RYGB) and a common indication for surgical revision. We aimed to develop a simple clinically applicable prediction score that can identify patients at high risk for MU to target with early screening protocols and medical interventions. Methods: We retrospectively examined data from all post RYGB patients referred to our tertiary care bariatric center from July 2003 - October 2010. Detailed chart reviews were conducted on 150 patients that had confirmed MU on upper endoscopy and on 120 patients with no MU. These groups were compared to assess risk factors. We used half of the cohort (n ⫽ 135) to derive the prediction score. We then used the second half of the cohort (n ⫽ 135) to validate it. Results: Risk factors associated with MU formation included age ⱖ 50 (OR ⫽ 1.01, CI 0.4 2.5), presence of diabetes mellitus prior to RYGB (OR ⫽ 1.93, CI 0.73 - 5.13), cigarette smoking (OR ⫽ 2.6, CI 1.04 - 6.9), and being in the first three years after RYGB (OR ⫽ 4.9, CI 2.1 - 11). We converted these odd ratios to an 8 point scoring system based on their strength of association with MU formation. A cut-off score ⱖ 5 points out of 8 had an area under the receiver operating characteristic curve (ROS) of 0.74 and a positive predictive value (PPV) for predicting MU formation of 79%. The performance of the prediction score was similar in the validation cohort with an area under the ROS curve of 0.70 and a PPV for predicting MU formation with a score ⱖ 5 of 81%. Conclusion: This simple prediction score reliably stratifies patients at risk for MU formation after RYGB and may provide better patient outcomes through more aggressive screening and medical prophylactic protocols.
Sa1640 Thirty Cases of Heterotopic Pancreas: Experience From a Single High-Volume Medical Center in China Xitai Sun1, Ying Lu2, Qiang Li1, Qin Huang3,4 1 Department of Laparoscopic Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China; 2 Department of Gastroenterology, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China; 3Department of Pathology, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China; 4Department of Pathology and Laboratory Medicine, the Veterans Affairs Boston Healthcare System and Harvard Medical School, West Roxbury, MA Background and purpose: Heterotopic pancreas (HP) is a rare congenital condition and has been discovered more frequently in the symptom-oriented
www.giejournal.org
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB231
Sa1633 Endoscopic Treatment of Watermelon Stomach: Argon Plasma Coagulation Versus Band Ligation Ladislava Sebkova, Stefano Rodino’, Teresa D’Amico, Natale Saccà Gastroenterology Unit, Azienda Ospedaliera Pugliese-Ciaccio, Catanzaro, Italy Background: Watermelon stomach is well-known cause of gastrointestinal bleeding and anemia. Argon plasma coagulation (APC) was demonstrated safe and effective for the treatment of watermelon stomach. Recent data suggested the possibility of treatment with endoscopic band ligation (EBL). Objective: Retrospective study designed to compare APC versus EBL treatment for watermelon stomach treatment valuating number of treatments, days of hospitalization and transfusion requirement. Patients: In the study were included 15 patients (9 females, median age 68 years, range 32-87) treated for watermelon stomach at our endoscopic unit between January 2007 until March 2009, Patients were followed-up for 6 months after eradication of antral vascular ectasia. Results: Patients treated with APC were 10 and with EBL were 5. Both methods were successful for eradication of antral vascular ectasia. Significant differences were found in number of treatment session (1,6 in EBL vs 4,6 in APC group), greater decrease in transfusion requirement (2,8 units in EBL vs 6,8 units in APC group) and greater decrease in days of hospitalization during the treatment and the follow-up (4,2 days of EBL vs 8,6 days in APC group). Before treatment no significant differences in the demographics, clinical presentation and mean hemoglobin values were observed between both groups. Conclusion: APC and EBL treatment of watermelon stomach are both effective and safe. Our initial experience suggests superior results for EBL reducing mainly number of treatment session to obtain complete eradication of antral vascular ectasia. In our opinion other advantages (reduced transfusion requirement and days of hospitalization) are secondary to the faster eradication of antral vascular ectasia due to important reduction of treatment session. Unlike APC, EBL can be applied all over the antrum in a single session, and because it’s simple method that does not require any expensive equipment, accessories, or advanced training. Other, probably multicenter studies, are necessary to show clearly advantages of single method.
Sa1634 Utilization of the Critical Care Unit for Emergency Endoscopic Treatment At Night or Weekends Improved the Mortality Rate for Patients With Non-Variceal Upper Gastrointestinal Bleeding Masao Toki, Yasuharu Yamaguchi, Kenji Nakamura, Shin’Ichi Takahashi The 3rd Dept. of Med, Kyorin Univ. School of Med., Tokyo, Japan [Aims] Our hospital is one of the medical facilities playing a crucial role in critical care in Japan, annually accepting about 35,000 emergency patients. On a daily basis, staff insufficiency is marked for emergency endoscopic treatment, especially at night and weekends. Thus, we investigated the current status of emergency endoscopic treatment at night and weekends in our hospital and explored valid means of improving the mortality for patients received emergency endoscopic treatment. [Methods] ⬍Study 1⬎ The study involved 2039 patients having undergone emergency endoscopic treatment between January 2005 and July 2007. Among these patients, 6 died. We analyzed the factors of these 6 fatal patients in detail. ⬍Study 2⬎ From results of Study 1, we adopted the strategy that the Critical Care Unit would be utilized for emergency endoscopy at night and weekends for both inpatients and outpatients with non-variceal upper gastrointestinal bleeding (NUGIB). This strategy was adopted for the following reasons: (1) The Critical Care Unit is staffed adequately even at night and weekends, making it easy to secure manpower needed for treatment. (2) Sudden changes in the patients condition can be smoothly dealt with under support by nurses experienced with critical care. (3) Help by physicians specializing in critical care is available in case of sudden changes of the patient’s condition. (4) The endoscopist can concentrate on hemostasis if adequate manpower is available. (5) The unit has an angiography room and an operating room. Thus, it is smooth to transfer to the 2nd line treatment such as angiography or surgery for patients with endoscopic refractory NUGIB. We investigated whether utilization of the Critical Care Unit for emergency endoscopic treatment at night or weekends improve the mortality rate for patients with NUGIB. [Results] ⬍Study 1⬎ The 6 patients who died were composed of 2 patients with gastric ulcer, 1 with gastric cancer, 1 with duodenal ulcer and 2 with other diseases. All of these 6 patients were carried to our hospital at night or weekends. Five of them underwent endoscopy in the insufficiently-staffed endoscopy room. ⬍Study 2⬎ During the period from August 2007 to October 2010, 146 patients underwent emergency endoscopy at night or weekends. No death was recorded among the patients for whom the Critical Care Unit was utilized for emergency endoscopic treatment at night or weekends. Smooth transfer to angiography (9 cases) and operation (3 cases) was possible during management of the 146 cases. Three patients suffered cardiac or respiratory arrest, but resuscitation was successful in all these cases. [Conclusion] Utilization of the Critical Care Center for emergency upper endoscopic treatment at night or weekends was shown to be beneficial for patient management and is expected to improve the mortality rate.
Sa1635 The Adequate Number of Biopsy Specimen in an Era of the HighQuality for the Diagnosis of Malignant or Premalignant Gastric Lesions: Preliminary Results of a Prospective Observational Study Hyoun Woo Kang, Jun Kyu Lee, Jae Hak Kim, Moon Soo Koh, Jin Ho Lee Internal medicine, Dongguk University College of Medicine, Goyang, Republic of Korea Background: Getting six pieces of biopsy specimen around a lesion is the most widely-used method when gastric malignancy is suspected on the esophagogastrodudenoscopic examination. This practice originates from one Japanese study conducted in 1970’s. However, endoscopists are being faced with some changes which force them to reconsideration this old principle. The resolution of the endoscope has improved dramatically and even the magnification to identify individual lining cells is possible nowadays. Endoscopists can target a lesion more accurately with this innovation. In addition, patients taking anti-platelet agents or warfarin have increased markedly due to expanding incidences of cardiovascular disease and stroke. Performing biopsy in these patients might cause significant bleeding, and the chances increase when more pieces of specimen are bitten. Aim: The authors intended to reassess the optimal numbers of biopsy specimen for the diagnosis of gastric cancer in an era of the high-quality endoscopy. Methods: A total 84 gastric lesions which were endoscopically-suspected by experienced endoscopists for having malignant or premalignant were prospectively included at the Dongguk University Ilsan Hospital from Jan 2008 to Dec 2009. Six pieces of biopsy specimen per lesion were gathered separately in order and analyzed pathologically. Results: Sixty were diagnosed as malignant or premalignant gastric lesions, and 5, 32, and 25 were finally diagnosed as gastric adenoma, early gastric cancer, or advanced gastric cancer (AGC), respectively. Positive results were obtained in 47 (78.3%), 53 (88.3%), 54 (90%), 59 (98.3%), 59 (98.3%) and 60 (100%) out of 60 lesions on the 1st, 2nd, 3rd, 4th, 5th and 6th specimen cumulatively. Five out of 6 cases, which showed the false negative results upto the 4th specimen were finally diagnosed as AGC, Borrmann type 4. No significant bleeding happened during the study period. Conclusions: Taking four pieces of biopsy specimen is sufficient when a malignant or premalignant gastric lesion is suspected endoscopically with an exception of AGC, Borrmann type 4.
Sa1636 Buried Bumper Syndrome: Prevalence and Endoscopic Management Marianna Arvanitakis1,2, Ziad El Ali1, Asuncion Ballarin2, Jacques M. E. Deviere1, Olivier Le Moine1, Andre M. Van Gossum1,2 1 Gastroenterology, Erasme University Hospital, Brussels, Belgium; 2 Nutrition Team, Erasme University Hospital, Brussels, Belgium Rationale: Buried bumper syndrome (BBS) is a rare long-term complication of percutaneous endoscopic gastrostomy (PEG) and consists of a progressive impaction of the inner bumper of the tube in the gastric wall, resulting from excessive traction and overtightening of the outer flange. The aim of our study was to report our own experience with patients with BBS, focusing on their endoscopic management. Methods: Medical records of 879 patients having undergone PEG insertion (2002-2009) were retrospectively reviewed. Patients presenting with BBS during their follow-up were noted, including clinical data and endoscopic management. Results: Eight patients (8/879; 0.9%) developed BBS, which was confirmed during gastroscopy. The mean time between PEG insertion and the BBS diagnosis was 36 ⫾ 31 months. A critically-ill patient died shortly after the diagnosis, and in two patients BBS was managed surgically. The needle-knife excision technique was used to remove the buried bumper in 5 patients. A flexible guide wire was inserted through the internal orifice of the PEG to define anatomical settings. Next, cruciform excisions of the mucosa were performed with the needle-knife starting at the center of the mucosal dome covering the internal bumper, and reaching its edges. Subsequently, the bumper was extruded and completely extracted, through the gastric tract, with a standard rat tooth forceps. A new replacement balloon gastrostomy was inserted in the PEG orifice during the same procedure. All patients received antibiotics during the procedure. Length of stay related to BBS treatment was 6.7 ⫾ 4.2 days. No complications were noted. Conclusions: Buried bumper syndrome is a rare longterm PEG complication. It can be prevented by avoiding over traction of the outer flange and assuring tube mobilization during follow-up. A useful and safe technique to treat BBS is mucosal excision with the needle-knife.
Sa1637 Direct Percutaneous Endoscopic Jejunostomy: A Retrospective Analysis of Indications, Success and Outcome Marianna Arvanitakis1,2, Asuncion Ballarin2, Jacques M. E. Deviere1, Olivier Le Moine1, Andre M. Van Gossum1,2 1 Gastroenterology, Erasme University Hospital, Brussels, Belgium; 2 Nutrition Team, Erasme University Hospital, Brussels, Belgium Rationale: Percutaneous access to the jejunum can provide enteral feeding if the gastric route is not possible. The aim of this study was to evaluate indications, success rate, short- and long-term complications and outcome in patients in
AB230 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
Abstracts
whom a percutaneous endoscopic jejunostomy (PEJ) was performed. Methods: Clinical data concerning patients in whom a PEJ was scheduled between 1/2006 and 1/2010 were retrospectively collected and analyzed. Results: Twenty-two patients were included. In 4 patients, the procedure was unsuccessful, due to lack of translumination; therefore the success rate was 81%. In 3 of these patients, a percutaneous endoscopic gastrostomy with a jejunal extension was placed and one patient underwent surgery. The remaining 18 patients (10 men, 8 women) who underwent successful PEJ placement had a median age of 57 years (22-79) and a body mass index of 18,5 (13-33). Regarding underlying disease, 5 patients (27.8%) had previous lung transplantation and 7 (38.9%) had gastrectomy. Indications for jejunal access were as follows: gastroparesis (n⫽5, 27.8%), gastrectomy (n⫽7, 38.9%) and severe reflux (n⫽6, 33.3%). Eight patients had previous nasogastric (n⫽2) or nasojejunal (n⫽6) tube. An enteroscope was used in 11 patients, whereas a gastroscope was used in 6 and a pediatric colonoscope in 1 patient. Eighteen french tubes with an internal bumper were used in all patients. No patient presented with short-term complications. Six patients had long-term complications (tube migration and local infection). Seven patients required a second procedure during follow-up. Enteral feeding was well tolerated in 13 patients (72.2%) and weight gain was observed in 6 (33.3%). Total median length of jejunal feeding was 6 months (1-36). Conclusions: PEJ is a useful endoscopic alternative for providing enteral nutrition when gastrostomy is not possible. Frequent indications in our series include previous gastrectomy and gastroparesis following lung transplantation.
Sa1638 Risk Factors for Local Recurrence After En Bloc Resection of Endoscopic Submucosal Dissection for the Early Gastric Cancer Treatment Eunsoo Kim, Kwangbum Cho, Kyung Sik Park Internal medicine, Keimyung University School of Medicine, Daegu, Republic of Korea Backgrounds/Aim: Endoscopic submucosal dissection (ESD) has been accepted as an alternative method to surgery for the treatment of early gastric cancer (EGC). Piecemeal resection has been reported to be associated with the local recurrence after ESD. However, there is no study evaluating local recurrence after en bloc resection of ESD. The aim of this study was to assess risk factors for local recurrence after en bloc resection of ESD for the treatment of EGC. Methods: From April 2003 to May 2010, patients with EGC treated by ESD and followed up for at least 6 months were eligible for this study and their medical records were evaluated retrospectively. We excluded the lesions removed by the way of a piecemeal resection and involved in the deep margin pathologically. The lesions with lateral safety margin less than 1 mm was considered as the inadequate group. Results: Among 1,215 gastric epithelial lesions in 1,121 patients, 415 EGC lesions in 401 patients were included (median age 66 (32-87), male 291, median follow-up month 14.8). The overall recurrence rate was 8.7% (36/415) and EGC with ill defined margin was identified as a significant independent risk factor for local recurrence in the multivariate analysis (OR 2.369, 95% CI 1.101-5.098, p⫽0.027). The cumulative recurrence was more observed in the inadequate group (lateral safety margin ⬍1 mm) through Kaplan-Meier analysis (p⫽0.019). Multivariate predictive factor for inadequate lateral safety margin was the tumor location (upper third vs. lower third, p⬍0.001). Conclusion: Aside from achievement of en bloc resection during ESD, efforts should be made to identify the clear lateral margin of tumor for avoiding local recurrence. Endoscopists should pay attention to obtain an adequate tumor safety margin especially in upper-located gastric tumor lesions.
Sa1639 Prediction Score for Marginal Ulcer Formation After Roux-en-Y Gastric Bypass Barham K. Abu Dayyeh1,2, Pichamol Jirapinyo1, Dan E. Azagury3, Christopher C. Thompson1 1 Division of Gastroenterology, Brigham & Women’s Hospital, Boston, MA; 2Gastrointestinal Unit, Massachusetts General Hospital, Boston, MA; 3Bariatric/Minimally Invasive Surgery, Brigham & Women’s Hospital, Boston, MA Background & Aims: Marginal ulceration (MU) is a frequent complication after Roux-en-Y gastric bypass (RYGB) and a common indication for surgical revision. We aimed to develop a simple clinically applicable prediction score that can identify patients at high risk for MU to target with early screening protocols and medical interventions. Methods: We retrospectively examined data from all post RYGB patients referred to our tertiary care bariatric center from July 2003 - October 2010. Detailed chart reviews were conducted on 150 patients that had confirmed MU on upper endoscopy and on 120 patients with no MU. These groups were compared to assess risk factors. We used half of the cohort (n ⫽ 135) to derive the prediction score. We then used the second half of the cohort (n ⫽ 135) to validate it. Results: Risk factors associated with MU formation included age ⱖ 50 (OR ⫽ 1.01, CI 0.4 2.5), presence of diabetes mellitus prior to RYGB (OR ⫽ 1.93, CI 0.73 - 5.13), cigarette smoking (OR ⫽ 2.6, CI 1.04 - 6.9), and being in the first three years after RYGB (OR ⫽ 4.9, CI 2.1 - 11). We converted these odd ratios to an 8 point scoring system based on their strength of association with MU formation. A cut-off score ⱖ 5 points out of 8 had an area under the receiver operating characteristic curve (ROS) of 0.74 and a positive predictive value (PPV) for predicting MU formation of 79%. The performance of the prediction score was similar in the validation cohort with an area under the ROS curve of 0.70 and a PPV for predicting MU formation with a score ⱖ 5 of 81%. Conclusion: This simple prediction score reliably stratifies patients at risk for MU formation after RYGB and may provide better patient outcomes through more aggressive screening and medical prophylactic protocols.
Sa1640 Thirty Cases of Heterotopic Pancreas: Experience From a Single High-Volume Medical Center in China Xitai Sun1, Ying Lu2, Qiang Li1, Qin Huang3,4 1 Department of Laparoscopic Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China; 2 Department of Gastroenterology, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China; 3Department of Pathology, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China; 4Department of Pathology and Laboratory Medicine, the Veterans Affairs Boston Healthcare System and Harvard Medical School, West Roxbury, MA Background and purpose: Heterotopic pancreas (HP) is a rare congenital condition and has been discovered more frequently in the symptom-oriented
www.giejournal.org
Volume 73, No. 4S : 2011
GASTROINTESTINAL ENDOSCOPY
AB231