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Sa1648 Direct Percutaneous Endoscopic Jejunostomy Using a Small-Gauge Finder Needle
Abstracts
Sa1647 Surveillance of Gastric Ulcer in a Hispanic and African American Predominant Community Prospere Remy, Haritha R. Chelimilla, Umair Siddiqui, Harish Patel, Myrta Daniel, David Widjaja Medicine, Bronx Lebanon Hospital Center, Bronx, NY Background: Endoscopic surveillance for benign gastric ulcer (GU) has been a common practice although it is neither recommended by the US GI societies nor is cost effective. Furthermore, the yield of the endoscopic surveillance in Hispanic and African American community has not been studied, particularly with the advent of Helicobacter Pylori (HP) treatment. Purpose: To analyze key factors and outcomes associated with endoscopic surveillance of GU in our South Bronx hospital. Methods: Persons aged 18 years or older who were diagnosed with GU on initial esophagogastroduodenoscopy (EGD) at GI division of Bronx Lebanon Hospital Center between January 1, 2002 and April 30 2010 were included in this retrospective study. Exclusion criteria included the presence of gastric malignancy on initial EGD and GU during percutaneous endoscopic gastrostomy tube placement. Repeat EGD in less than 28 days was not considered as surveillance of GU. Results: We reviewed 1327 patients who were found to have GU. Among these patients, 637 (48%) were Hispanic and 610 (46%) were African American. The mean age (⫹ SD) was 58 (⫹14) year old. Of all the patients, 430 (32%) had repeat EGD with median interval between the EGDs of 24 weeks. There were no significant difference in mean age (p⫽0.12) and gender (p⫽0.68) between patients who underwent and those who did not undergo repeat EGD. Among the 430 patients who underwent repeat EGD, 301 (70%) had initial EGD in ambulatory setting, while only 129 (30%) had initial EGD during hospitalization (p⬍0.0001). Of the 430 patients who had repeat EGD, 229 (53%) had persistent GU. Gastric biopsy of the 229 patients with persistent GU showed presence of HP by histology (10%), positive CLO test (9%) and dysplasia (2%). None of the patients with persistent GU had gastric malignancy. The presence of persistent GU was not associated with the presence of positive CLO test (p⫽0.3), HP (p⫽0.09), or dysplasia (p⫽0.3) on initial gastric biopsy. Positive CLO test on repeat EGD was associated with positive CLO test (OR⫽ 5.8, p⬍0.0001) and the presence of HP on initial EGD (OR⫽3.5, p⫽0.01). The presence of HP on repeat EGD was associated with positive CLO test (OR⫽3.5, p⬍0.0001) and the presence of HP (OR⫽4, p⫽0.002) on initial EGD. The presence of dysplasia on repeat biopsy was associated with initial finding of dysplasia (OR⫽105, p⬍0.0001). Conclusions: Among minorities with GU who underwent surveillance, 53% had persistent GU. The presence of positive CLO test, HP and dysplasia on repeat EGD was associated with same findings on initial EGD. Although none of them developed gastric malignancy during the follow up period, surveillance of GU in this community needs to be considered if HP and dysplasia are observed on initial EGD.
Sa1648 Direct Percutaneous Endoscopic Jejunostomy Using a SmallGauge Finder Needle Huseyin Aktas, Jaap Driest, Arjun D. Koch, Ernst J. Kuipers, Henk R. Van Buuren Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands Background: Direct percutaneous endoscopic jejunostomy (DPEJ) is an effective method for providing enteral nutrition when percutaneous endoscopic gastrostomy (PEG) is not feasible because of anatomical or functional abnormalities. However it can be difficult to puncture a mobile or deep jejunal loop with conventional 15-18 french PEG trocars, and repeated attempts may increase the risk of complication. As we were not comfortable with reported DPEJ techniques, including the method using the 5 french Kellett drainage needle we aimed to develop a less traumatic and thereby possibly safer technique using an ultrathin finder needle and wire. Methods: Prospectively, consecutive patients requiring enteral tube feeding and undergoing DPEJ using the single-balloon enteroscopy (Olympus XSIF-Q160Y) were evaluated at an academic tertiary referral center. With the tip of the enteroscope in the proximal jejunum, transillumination was used for determining the site of insertion. After local anesthesia a 21-gauge, 4 cm long finder needle was advanced into the jejunum. To confirm that no loops of bowel were interposed between the jejunum and abdominal wall, the “safe track” maneuver was performed by aspirating with the plunger during withdrawal of the needle. The finder needle was then reinserted into the jejunum and snared, and subsequently an ultrathin wire (fishing line) was introduced. This wire is then grasped with the biopsy forceps and pulled out through the mouth. The rest of the procedure was similar to conventional pull PEG procedures. A 15 french (Freka®) feeding catheter was inserted. Rate of successful jejunal tube placement and complications, directly and 30 days after the procedure were assessed. Results: During a 2 month period, 5 DPEJ procedures were performed with this refined needle technique: M/F 3/2, mean age 62 (58-67) years. All procedures were performed under conscious sedation using midazolam and fentanyl. The indications for DPEJ were gastric dysmotility (n⫽2), recurrent aspiration pneumonia (n⫽1), gastric cancer (n⫽1) and jejunal levodopa infusion in Parkinson’s disease (n⫽1). Three patients
had previously been treated with PEG. DPEJ was successful in all 5 cases. The operators considered this technique easier than methods previously used. There were no procedural complications. Conclusion: DPEJ can be performed successfully using a non-traumatic 21-gauge finder needle instead of conventional, thicker trocars or needles. More experience is necessary to determine whether this approach is indeed superior to previously reported methods.
Sa1649 Clinical Outcomes of Endoscopic Submucosal Dissection (ESD) for Undifferentiated and Poorly Differentiated Early Gastric Adenocarcinoma Isao Fujita, Tatsuya Toyokawa, Joichiro Horii, Jun Tomoda Department of gastroenterology, Fukuyama Medica Center, Fukuyama, Japan Background: ESD has been established as a standard treatment for early gastric cancers in Japan. However, the indications for undifferentiated and poorly differentiated (UPD) gastric adenocarcinoma are controversial because of lymph node metastasis. This study aimed to evaluate clinical outcomes of ESD for early gastric cancer of both UPD types compared to those of surgical resection. Methods: We investigated 436 lesions of early gastric cancer treated with ESD from 2002 to 2009, at the Fukuyama Medical Center. Among those were, 17 lesions of UPD early gastric cancer. 45 lesions of UPD early gastric cancer treated with surgical resection during the same periods were also investigated. We investigated the risk factors for lymphatic permeation with UPD gastric cancer. Results: Of the 17 lesions of UPD early gastric cancer, the average lesion size was 15 mm, and none exhibited ulceration or lymphatic permeation. The complete resection rate was 88% (15/17), and only one case presented with local recurrence. Lesions size, procedure time, complete resection rate, and frequency of procedure-related complications were similar between these 17 lesions and the 419 lesions treated with ESD. Next we investigated the lesions that were surgically treated. We examined 20 lesions of UPD intramucosal gastric cancer; their average lesion size was 26 mm, and 7 cases exhibited ulcerations. Lymphatic permeation was detected in 1 case with ulceration, but lymph node metastasis not detected. We also had 25 lesions of UPD gastric cancer with submucosal invasion. Of these 25 lesions, the average size was 27 mm and 18 cases had ulcerations. Lymphatic permeation was detected in 16 cases, and node metastasis was detected in 2 cases. Although the lesions size was no different between cases of intramucosal cancers and cancers with submucosal invasion, lesions of cancers with submucosal invasion had significantly more ulcerations and lymphatic permeation. Finally, we analyzed 62 lesions of UPD early gastric cancer treated with ESD and surgical resection. Risk factors for lymphatic permeation included lesion size, depth of invasion, and ulceration on univariate logistic regression analysis. In multivariate logistic regression analysis, risk factors for lymphatic permeation were size of lesion and depth of invasion. Conclusions: ESD for intramucosal gastric cancer of undifferentiated and poorly differentiated type is as safe as that with differentiated cancer. In this study, we demonstrated the risk factors for lymphatic permeation with undifferentiated and poorly differentiated gastric cancer. ESD for undifferentiated and poorly differentiated gastric adenocarcinoma was acceptable if it could be performed bearing in mind the presence of risk factors.
Sa1650 Endoscopic Submucosal Dissection (ESD) Compared to Radical Gastrectomy for Treatment of Early Gastric Cancer Philip W. Chiu, Anthony Y. Teoh, Shirley Y. Liu, Candice C. Lam, Man Yee Yung, Simon K. Wong, Enders K. Ng Surgery, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China Introduction: ESD emerged as a novel endoscopic treatment for early gastric cancer which can achieve en-bloc resection with wide margins. There is no comparative study on clinical outcomes of ESD against conventional gastrectomy for treatment of early gastric cancer (EGC). This study aimed to compare the perioperative outcomes and oncological clearance for treatment of EGC between radical gastrectomy and ESD. Method: This is a retrospective case control study which included all cases of severe dysplasia or early gastric cancer treated at the Prince of Wales Hospital, Chinese University of Hong Kong since 1993. EGC is defined as carcinoma involving mucosa or submucosa, and EGC were treated with radical subtotal or total gastrectomy before ESD was introduced in 2004. EUS, magnifying endoscopy and CT abdomen were employed for preoperative staging and determination of depth of invasion. Clinical outcomes, including baseline demographics, preoperative pathology and staging, postoperative complication and hospital stay, as well as 3 year survival were compared. Results: From 1993 to 2010, 134 patients with severe dysplasia or early gastric cancer were treated at our unit. The mean age of patients was 64.5 years with 88 male and 46 female. 40 patients were treated with gastrectomy, while 94 received ESD. There is no difference in gender distribution, comorbidity and ASA
AB234 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
Sa1647 Surveillance of Gastric Ulcer in a Hispanic and African American Predominant Community Prospere Remy, Haritha R. Chelimilla, Umair Siddiqui, Harish Patel, Myrta Daniel, David Widjaja Medicine, Bronx Lebanon Hospital Center, Bronx, NY Background: Endoscopic surveillance for benign gastric ulcer (GU) has been a common practice although it is neither recommended by the US GI societies nor is cost effective. Furthermore, the yield of the endoscopic surveillance in Hispanic and African American community has not been studied, particularly with the advent of Helicobacter Pylori (HP) treatment. Purpose: To analyze key factors and outcomes associated with endoscopic surveillance of GU in our South Bronx hospital. Methods: Persons aged 18 years or older who were diagnosed with GU on initial esophagogastroduodenoscopy (EGD) at GI division of Bronx Lebanon Hospital Center between January 1, 2002 and April 30 2010 were included in this retrospective study. Exclusion criteria included the presence of gastric malignancy on initial EGD and GU during percutaneous endoscopic gastrostomy tube placement. Repeat EGD in less than 28 days was not considered as surveillance of GU. Results: We reviewed 1327 patients who were found to have GU. Among these patients, 637 (48%) were Hispanic and 610 (46%) were African American. The mean age (⫹ SD) was 58 (⫹14) year old. Of all the patients, 430 (32%) had repeat EGD with median interval between the EGDs of 24 weeks. There were no significant difference in mean age (p⫽0.12) and gender (p⫽0.68) between patients who underwent and those who did not undergo repeat EGD. Among the 430 patients who underwent repeat EGD, 301 (70%) had initial EGD in ambulatory setting, while only 129 (30%) had initial EGD during hospitalization (p⬍0.0001). Of the 430 patients who had repeat EGD, 229 (53%) had persistent GU. Gastric biopsy of the 229 patients with persistent GU showed presence of HP by histology (10%), positive CLO test (9%) and dysplasia (2%). None of the patients with persistent GU had gastric malignancy. The presence of persistent GU was not associated with the presence of positive CLO test (p⫽0.3), HP (p⫽0.09), or dysplasia (p⫽0.3) on initial gastric biopsy. Positive CLO test on repeat EGD was associated with positive CLO test (OR⫽ 5.8, p⬍0.0001) and the presence of HP on initial EGD (OR⫽3.5, p⫽0.01). The presence of HP on repeat EGD was associated with positive CLO test (OR⫽3.5, p⬍0.0001) and the presence of HP (OR⫽4, p⫽0.002) on initial EGD. The presence of dysplasia on repeat biopsy was associated with initial finding of dysplasia (OR⫽105, p⬍0.0001). Conclusions: Among minorities with GU who underwent surveillance, 53% had persistent GU. The presence of positive CLO test, HP and dysplasia on repeat EGD was associated with same findings on initial EGD. Although none of them developed gastric malignancy during the follow up period, surveillance of GU in this community needs to be considered if HP and dysplasia are observed on initial EGD.
Sa1648 Direct Percutaneous Endoscopic Jejunostomy Using a SmallGauge Finder Needle Huseyin Aktas, Jaap Driest, Arjun D. Koch, Ernst J. Kuipers, Henk R. Van Buuren Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands Background: Direct percutaneous endoscopic jejunostomy (DPEJ) is an effective method for providing enteral nutrition when percutaneous endoscopic gastrostomy (PEG) is not feasible because of anatomical or functional abnormalities. However it can be difficult to puncture a mobile or deep jejunal loop with conventional 15-18 french PEG trocars, and repeated attempts may increase the risk of complication. As we were not comfortable with reported DPEJ techniques, including the method using the 5 french Kellett drainage needle we aimed to develop a less traumatic and thereby possibly safer technique using an ultrathin finder needle and wire. Methods: Prospectively, consecutive patients requiring enteral tube feeding and undergoing DPEJ using the single-balloon enteroscopy (Olympus XSIF-Q160Y) were evaluated at an academic tertiary referral center. With the tip of the enteroscope in the proximal jejunum, transillumination was used for determining the site of insertion. After local anesthesia a 21-gauge, 4 cm long finder needle was advanced into the jejunum. To confirm that no loops of bowel were interposed between the jejunum and abdominal wall, the “safe track” maneuver was performed by aspirating with the plunger during withdrawal of the needle. The finder needle was then reinserted into the jejunum and snared, and subsequently an ultrathin wire (fishing line) was introduced. This wire is then grasped with the biopsy forceps and pulled out through the mouth. The rest of the procedure was similar to conventional pull PEG procedures. A 15 french (Freka®) feeding catheter was inserted. Rate of successful jejunal tube placement and complications, directly and 30 days after the procedure were assessed. Results: During a 2 month period, 5 DPEJ procedures were performed with this refined needle technique: M/F 3/2, mean age 62 (58-67) years. All procedures were performed under conscious sedation using midazolam and fentanyl. The indications for DPEJ were gastric dysmotility (n⫽2), recurrent aspiration pneumonia (n⫽1), gastric cancer (n⫽1) and jejunal levodopa infusion in Parkinson’s disease (n⫽1). Three patients
had previously been treated with PEG. DPEJ was successful in all 5 cases. The operators considered this technique easier than methods previously used. There were no procedural complications. Conclusion: DPEJ can be performed successfully using a non-traumatic 21-gauge finder needle instead of conventional, thicker trocars or needles. More experience is necessary to determine whether this approach is indeed superior to previously reported methods.
Sa1649 Clinical Outcomes of Endoscopic Submucosal Dissection (ESD) for Undifferentiated and Poorly Differentiated Early Gastric Adenocarcinoma Isao Fujita, Tatsuya Toyokawa, Joichiro Horii, Jun Tomoda Department of gastroenterology, Fukuyama Medica Center, Fukuyama, Japan Background: ESD has been established as a standard treatment for early gastric cancers in Japan. However, the indications for undifferentiated and poorly differentiated (UPD) gastric adenocarcinoma are controversial because of lymph node metastasis. This study aimed to evaluate clinical outcomes of ESD for early gastric cancer of both UPD types compared to those of surgical resection. Methods: We investigated 436 lesions of early gastric cancer treated with ESD from 2002 to 2009, at the Fukuyama Medical Center. Among those were, 17 lesions of UPD early gastric cancer. 45 lesions of UPD early gastric cancer treated with surgical resection during the same periods were also investigated. We investigated the risk factors for lymphatic permeation with UPD gastric cancer. Results: Of the 17 lesions of UPD early gastric cancer, the average lesion size was 15 mm, and none exhibited ulceration or lymphatic permeation. The complete resection rate was 88% (15/17), and only one case presented with local recurrence. Lesions size, procedure time, complete resection rate, and frequency of procedure-related complications were similar between these 17 lesions and the 419 lesions treated with ESD. Next we investigated the lesions that were surgically treated. We examined 20 lesions of UPD intramucosal gastric cancer; their average lesion size was 26 mm, and 7 cases exhibited ulcerations. Lymphatic permeation was detected in 1 case with ulceration, but lymph node metastasis not detected. We also had 25 lesions of UPD gastric cancer with submucosal invasion. Of these 25 lesions, the average size was 27 mm and 18 cases had ulcerations. Lymphatic permeation was detected in 16 cases, and node metastasis was detected in 2 cases. Although the lesions size was no different between cases of intramucosal cancers and cancers with submucosal invasion, lesions of cancers with submucosal invasion had significantly more ulcerations and lymphatic permeation. Finally, we analyzed 62 lesions of UPD early gastric cancer treated with ESD and surgical resection. Risk factors for lymphatic permeation included lesion size, depth of invasion, and ulceration on univariate logistic regression analysis. In multivariate logistic regression analysis, risk factors for lymphatic permeation were size of lesion and depth of invasion. Conclusions: ESD for intramucosal gastric cancer of undifferentiated and poorly differentiated type is as safe as that with differentiated cancer. In this study, we demonstrated the risk factors for lymphatic permeation with undifferentiated and poorly differentiated gastric cancer. ESD for undifferentiated and poorly differentiated gastric adenocarcinoma was acceptable if it could be performed bearing in mind the presence of risk factors.
Sa1650 Endoscopic Submucosal Dissection (ESD) Compared to Radical Gastrectomy for Treatment of Early Gastric Cancer Philip W. Chiu, Anthony Y. Teoh, Shirley Y. Liu, Candice C. Lam, Man Yee Yung, Simon K. Wong, Enders K. Ng Surgery, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China Introduction: ESD emerged as a novel endoscopic treatment for early gastric cancer which can achieve en-bloc resection with wide margins. There is no comparative study on clinical outcomes of ESD against conventional gastrectomy for treatment of early gastric cancer (EGC). This study aimed to compare the perioperative outcomes and oncological clearance for treatment of EGC between radical gastrectomy and ESD. Method: This is a retrospective case control study which included all cases of severe dysplasia or early gastric cancer treated at the Prince of Wales Hospital, Chinese University of Hong Kong since 1993. EGC is defined as carcinoma involving mucosa or submucosa, and EGC were treated with radical subtotal or total gastrectomy before ESD was introduced in 2004. EUS, magnifying endoscopy and CT abdomen were employed for preoperative staging and determination of depth of invasion. Clinical outcomes, including baseline demographics, preoperative pathology and staging, postoperative complication and hospital stay, as well as 3 year survival were compared. Results: From 1993 to 2010, 134 patients with severe dysplasia or early gastric cancer were treated at our unit. The mean age of patients was 64.5 years with 88 male and 46 female. 40 patients were treated with gastrectomy, while 94 received ESD. There is no difference in gender distribution, comorbidity and ASA
AB234 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org