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Safety of Transesophageal Echocardiography in Patients with Known Gastroesophageal Varices: A Case Series
Abstracts
W1405 Induced Transient Lower Esophageal Sphincter Relaxation in Normal Control Subjects and Patients with GERD Anil K. Vegesna, Mansoor I. Tiwana, Amit Kalra, Ramashesai Besetty, Barry Levitt, Robert S. Fisher, Henry P. Parkman, Larry S. Miller
W1407 Safety of Transesophageal Echocardiography in Patients with Known Gastroesophageal Varices: A Case Series Bret J. Spier, Shane Larue, Thomas Teelin, Lisa Swize, Samantha H. Borkan, Patrick Pfau
Background: Transient lower esophageal sphincter relaxations (TLESRs) are difficult to study because they are infrequent isolated events. Purpose: To develop a new method to induce TLESR. To determine the intragastric pressure and volume threshold for inducing TLESR in normal control subjects and patients with GERD. Methods: 13 normal volunteers and 3 patients with GERD all without hiatal hernias, underwent endoscopy. During the endoscopy a water perfused pressure transducer was placed through the biopsy channel of the endoscope. A gastric baseline pressure was measured. The endoscope was retroflexed and air was insufflated into the stomach through the endoscope until the gastroesophageal junction (GEJ) opened. The volume of air and the pressure above the baseline were measured at the time of GEJ opening. Results: There were two patterns of GEJ opening in the normal subjects. In pattern I (10 normal subjects) the hiatus slowly stretches and deforms, however the hiatus and distal esophagus opened simultaneously. The mean gastric pressure and volume at the point of distal esophageal opening in pattern I was 11.5 8.6 mmHg and 1284.15 mL þ/- 570.23 mL. In pattern II (5 normal subjects, 2 of the normal subjects had overlap between patterns I and II) the hiatus of the GEJ opened rapidly after insufflation of air into the stomach. Then, at some time point later and at a higher pressure and volume, the distal esophagus opened. The mean pressure and volume for hiatus opening and distal esophageal opening in pattern II in the normal subjects was 12.6 6.1mmHg and 1228.59 þ/763.97 mL for the hiatus and 19.7 1. and 1728.83 mL þ/- 660.34 mL for the distal esophagus. In the three GERD patients the mean gastric pressure and volume at hiatal opening was 3mmHg and 149.4 57.5 mL significantly lower than in the normal control subjects (pZ0.021). Conclusions: A new technique was developed and normative data for intragastric pressure and volume was collected for inducing TLESR. Two endoscopic patterns of TLESR were described in normal subjects. The gastroesophageal junction opened at a significantly lower pressure in patients with GERD compared to normal control subjects.
Background: The presence of gastroesophageal varices has been considered a relative contraindication to performing transesophageal echocardiography (TEE). The majority of studies evaluating TEE safety have excluded patients with known gastroesophageal varices and there is no present data to support not performing TEE in the presence of gastroesophageal varices. Aim: The aim of this study is to evaluate the safety and benefit of performing TEE in patients with portal hypertension and known gastroesophageal varices. Methods: We identified 14 patients who had known esophageal varices as documented by previous endoscopy who underwent TEE performed from 1997 to 2007. After IRB approval, we reviewed the patient’s chart for procedure related complications as well as benefit in performing TEE. Results: The 14 patients identified had an average age of 50.4 years. Nearly half (6 of 14) had moderate-large (grade R 2) esophageal varices at time of TEE. The varices were identified by endoscopy performed an average of 27 days prior to TEE (range 0 to 88 days; 2 performed for clearance prior to TEE). The most common etiology of portal hypertension was alcoholic liver disease (11 of 14) and the most common indication for TEE was to evaluate for endocarditis (11 of 14). At the time of TEE the average Model for End Stage Liver Disease (MELD) score was 18.3 (range 10 to 30) with average INR 1.6 (range 1.2 to 2.2) and average number of platelets 137,000 (range 35,000 to 372,000). No post procedure hematemesis, coffee ground emesis or melena occurred. There were no major bleeding episodes following TEE as defined by a decrease in hemoglobin of greater than 2 gm/dl in the 48 hours post-procedure. There were also no packed red blood cell (PRBC) transfusions related to performing the TEE. On one occasion there was blood tinting of the echo probe with an unrevealing endoscopy performed the following day. Each TEE performed provided clinical information that affected patient management. Conclusion: While the presence of known esophageal varices was previously thought to be a contraindication to performing TEE, our study has shown relative safety and a definite benefit in this patient population. To perform endoscopy for the indication of clearance prior to TEE is not necessary.
W1406 Long-Term Result of Photodynamic Therapy (PDT) As a Salvage Treatment for Patients with Local Failure After Definitive Chemoradiotherapy (CRT) for Esophageal Squamous Cell Carcinoma (ESCC) Tomonori Yano, Manabu Muto, Keiko Minashi, Masakatsu Onozawa, Kazuhiro Kaneko, Atsushi Ohtsu Background: Definitive CRT is one of the treatment options with curative intent for ESCC, however, local failure after completion of CRT remains one of the major problems in achieving a cure. While salvage esophagectomy is generally indicated for such patients, it shows relevant to high morbidity and mortality. We have previously reported the preliminary short-term results of salvage PDT after definitive CRT. Aim: The aim of this retrospective analysis was to clarify the longterm result of salvage PDT. Patients and Methods: All the patients had been treated with definitive CRT consist of more than 50 Gy of external beam irradiation and concurrent with platinum based chemotherapy. Local failure lesion was diagnosed with conventional endoscopy and endoscopic ultrasound (EUS). The criteria for salvage PDT were as follows; 1) no lymph-node and distant organ metastasis were detected with EUS and CT before PDT2) suspected lesion limited within T2 by EUS before PDT 3) patients‘ refusal of salvage esophagectomy 4) written informed consent. PDT was performed using excimer dye laser 48 and 72 hours after intravenous administration of Photofrin. Results: From December 2002 to February 2005, 37 patients (male/female: 35/2, median age: 64 y-o) underwent salvage PDT. Baseline clinical stage before CRT was as follows: T1/T2/T3/T4 in 3/4/24/6, N0/1 in 13/24 and stage I/II/III/IV (UICC-2002) in 2/11/22/2 patients. Ten patients had developed local recurrence after initially achieving complete response (CR) after CRT, and remaining 27 patients had had local residual tumors even after the completion of CRT. Before PDT, 20 patients were assessed having uT1 lesion and remaining 17 patients were uT2 by EUS. Twenty-two patients were achieved CR (CR rate; 59.4%) with salvage PDT. Esophageal stenosis required balloon dilation and phototoxicity occurred in 20 and 2 patients, respectively. Esophageal perforation occurred in 4 patients (10.8%), and one of them died with aortic rupture 63 days after PDT, and two of them were died of disease progression and another cured perforation with conservative treatment and achieved CR. With a median follow up period of 46 months after PDT, nine patients are still alive without recurrence and one patient died from another disease without recurrence. Of the 22 patients who could achieve CR with PDT, local recurrence occurred in six and lymph node or distant metastases were detected in six patients. The 3- and 5- year overall survival rates from the initiation of salvage PDT were 47.2% and 38.9%, respectively. Conclusion: Salvage PDT could be one of the curative treatment options for patients with local failure after definitive CRT for ESCC.
AB362 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
W1408 Screening for Esophagitis and Barrett’s Esophagus with Esophageal Capsule Endoscopy in First Degree Relatives of Patients Affected By Barrett’s Esophagus: Preliminary Results Alessandro Mussetto, Mauro Manno, Marzio Frazzoni, Rita Conigliaro Background and Aim: Barrett’s esophagus (BE) is one of the major complication of gastroesophageal reflux disease (GERD). Causes of its development are still not completely understood and genetics factors could play an important role. At our knowledge, there aren’t data regarding the prevalence of BE in first degree relatives of patients with BE. Recently, esophageal capsule endoscopy (ECE) has been proposed as a non invasive investigation of esophageal pathology. Our aims were to assess prospectively the prevalence of BE and GERD in first degree relatives of patients with BE and reflux symptoms and to evaluate the diagnostic yield of ECE in these conditions. Patients and Methods: Between July and October 2008, 14 patients (6 men, mean age 52 8) were enrolled. The inclusion criteria were familial history of one or more first-degree relative with BE (intestinal metaplasia histologically confirmed) and typical reflux syndrome. Patients underwent ECE followed by esophagogastroduodenoscopy (EGD). The endoscopist that performed EGD was blind to the ECE findings, which were assessed by an indipendent observer. EGD findings were considered gold standard. The Los Angeles score and Prague classification were adopted and the ECE findings were compared with those at EGD. Results: All the patients completed the study. Esophagitis and endoscopically suspected esophageal metaplasia (ESEM) were present, at ECE, in 6 and 10 patients, respectively. ESEM was present in 8 of 10 patients at EGD; in all cases intestinal metaplasia was detected at histology. Prevalence of BE in our series was 57%. The sensitivity, specificity, PPV and NPV of ECE for esophagitis were 83%, 88%, 83% and 88%, respectively. The sensitivity, specificity, PPV and NPV of ECE for ESEM were 100%, 67%, 80% and 100%, respectively. Conclusions: This is the first study that involves first degree-relatives of BE patients with reflux symptoms. We found that ECE is highly reliable in detecting ESEM, given its good PPV and optimal NPV, in a selected population with a high a-priori probability of BE. In fact, in our series there was a high prevalence of BE, while esophagitis was less present (42%). BE was detected in about 3% of cases in a typical reflux syndrome series recently investigated in our region. This higher prevalence could be explained with a familial, possibly genetic, component in the pathogenesis in BE. Pending confirmation of these preliminary results, we suggest that ECE could be proposed as a screening test in relatives of BE patients.
www.giejournal.org
W1405 Induced Transient Lower Esophageal Sphincter Relaxation in Normal Control Subjects and Patients with GERD Anil K. Vegesna, Mansoor I. Tiwana, Amit Kalra, Ramashesai Besetty, Barry Levitt, Robert S. Fisher, Henry P. Parkman, Larry S. Miller
W1407 Safety of Transesophageal Echocardiography in Patients with Known Gastroesophageal Varices: A Case Series Bret J. Spier, Shane Larue, Thomas Teelin, Lisa Swize, Samantha H. Borkan, Patrick Pfau
Background: Transient lower esophageal sphincter relaxations (TLESRs) are difficult to study because they are infrequent isolated events. Purpose: To develop a new method to induce TLESR. To determine the intragastric pressure and volume threshold for inducing TLESR in normal control subjects and patients with GERD. Methods: 13 normal volunteers and 3 patients with GERD all without hiatal hernias, underwent endoscopy. During the endoscopy a water perfused pressure transducer was placed through the biopsy channel of the endoscope. A gastric baseline pressure was measured. The endoscope was retroflexed and air was insufflated into the stomach through the endoscope until the gastroesophageal junction (GEJ) opened. The volume of air and the pressure above the baseline were measured at the time of GEJ opening. Results: There were two patterns of GEJ opening in the normal subjects. In pattern I (10 normal subjects) the hiatus slowly stretches and deforms, however the hiatus and distal esophagus opened simultaneously. The mean gastric pressure and volume at the point of distal esophageal opening in pattern I was 11.5 8.6 mmHg and 1284.15 mL þ/- 570.23 mL. In pattern II (5 normal subjects, 2 of the normal subjects had overlap between patterns I and II) the hiatus of the GEJ opened rapidly after insufflation of air into the stomach. Then, at some time point later and at a higher pressure and volume, the distal esophagus opened. The mean pressure and volume for hiatus opening and distal esophageal opening in pattern II in the normal subjects was 12.6 6.1mmHg and 1228.59 þ/763.97 mL for the hiatus and 19.7 1. and 1728.83 mL þ/- 660.34 mL for the distal esophagus. In the three GERD patients the mean gastric pressure and volume at hiatal opening was 3mmHg and 149.4 57.5 mL significantly lower than in the normal control subjects (pZ0.021). Conclusions: A new technique was developed and normative data for intragastric pressure and volume was collected for inducing TLESR. Two endoscopic patterns of TLESR were described in normal subjects. The gastroesophageal junction opened at a significantly lower pressure in patients with GERD compared to normal control subjects.
Background: The presence of gastroesophageal varices has been considered a relative contraindication to performing transesophageal echocardiography (TEE). The majority of studies evaluating TEE safety have excluded patients with known gastroesophageal varices and there is no present data to support not performing TEE in the presence of gastroesophageal varices. Aim: The aim of this study is to evaluate the safety and benefit of performing TEE in patients with portal hypertension and known gastroesophageal varices. Methods: We identified 14 patients who had known esophageal varices as documented by previous endoscopy who underwent TEE performed from 1997 to 2007. After IRB approval, we reviewed the patient’s chart for procedure related complications as well as benefit in performing TEE. Results: The 14 patients identified had an average age of 50.4 years. Nearly half (6 of 14) had moderate-large (grade R 2) esophageal varices at time of TEE. The varices were identified by endoscopy performed an average of 27 days prior to TEE (range 0 to 88 days; 2 performed for clearance prior to TEE). The most common etiology of portal hypertension was alcoholic liver disease (11 of 14) and the most common indication for TEE was to evaluate for endocarditis (11 of 14). At the time of TEE the average Model for End Stage Liver Disease (MELD) score was 18.3 (range 10 to 30) with average INR 1.6 (range 1.2 to 2.2) and average number of platelets 137,000 (range 35,000 to 372,000). No post procedure hematemesis, coffee ground emesis or melena occurred. There were no major bleeding episodes following TEE as defined by a decrease in hemoglobin of greater than 2 gm/dl in the 48 hours post-procedure. There were also no packed red blood cell (PRBC) transfusions related to performing the TEE. On one occasion there was blood tinting of the echo probe with an unrevealing endoscopy performed the following day. Each TEE performed provided clinical information that affected patient management. Conclusion: While the presence of known esophageal varices was previously thought to be a contraindication to performing TEE, our study has shown relative safety and a definite benefit in this patient population. To perform endoscopy for the indication of clearance prior to TEE is not necessary.
W1406 Long-Term Result of Photodynamic Therapy (PDT) As a Salvage Treatment for Patients with Local Failure After Definitive Chemoradiotherapy (CRT) for Esophageal Squamous Cell Carcinoma (ESCC) Tomonori Yano, Manabu Muto, Keiko Minashi, Masakatsu Onozawa, Kazuhiro Kaneko, Atsushi Ohtsu Background: Definitive CRT is one of the treatment options with curative intent for ESCC, however, local failure after completion of CRT remains one of the major problems in achieving a cure. While salvage esophagectomy is generally indicated for such patients, it shows relevant to high morbidity and mortality. We have previously reported the preliminary short-term results of salvage PDT after definitive CRT. Aim: The aim of this retrospective analysis was to clarify the longterm result of salvage PDT. Patients and Methods: All the patients had been treated with definitive CRT consist of more than 50 Gy of external beam irradiation and concurrent with platinum based chemotherapy. Local failure lesion was diagnosed with conventional endoscopy and endoscopic ultrasound (EUS). The criteria for salvage PDT were as follows; 1) no lymph-node and distant organ metastasis were detected with EUS and CT before PDT2) suspected lesion limited within T2 by EUS before PDT 3) patients‘ refusal of salvage esophagectomy 4) written informed consent. PDT was performed using excimer dye laser 48 and 72 hours after intravenous administration of Photofrin. Results: From December 2002 to February 2005, 37 patients (male/female: 35/2, median age: 64 y-o) underwent salvage PDT. Baseline clinical stage before CRT was as follows: T1/T2/T3/T4 in 3/4/24/6, N0/1 in 13/24 and stage I/II/III/IV (UICC-2002) in 2/11/22/2 patients. Ten patients had developed local recurrence after initially achieving complete response (CR) after CRT, and remaining 27 patients had had local residual tumors even after the completion of CRT. Before PDT, 20 patients were assessed having uT1 lesion and remaining 17 patients were uT2 by EUS. Twenty-two patients were achieved CR (CR rate; 59.4%) with salvage PDT. Esophageal stenosis required balloon dilation and phototoxicity occurred in 20 and 2 patients, respectively. Esophageal perforation occurred in 4 patients (10.8%), and one of them died with aortic rupture 63 days after PDT, and two of them were died of disease progression and another cured perforation with conservative treatment and achieved CR. With a median follow up period of 46 months after PDT, nine patients are still alive without recurrence and one patient died from another disease without recurrence. Of the 22 patients who could achieve CR with PDT, local recurrence occurred in six and lymph node or distant metastases were detected in six patients. The 3- and 5- year overall survival rates from the initiation of salvage PDT were 47.2% and 38.9%, respectively. Conclusion: Salvage PDT could be one of the curative treatment options for patients with local failure after definitive CRT for ESCC.
AB362 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009
W1408 Screening for Esophagitis and Barrett’s Esophagus with Esophageal Capsule Endoscopy in First Degree Relatives of Patients Affected By Barrett’s Esophagus: Preliminary Results Alessandro Mussetto, Mauro Manno, Marzio Frazzoni, Rita Conigliaro Background and Aim: Barrett’s esophagus (BE) is one of the major complication of gastroesophageal reflux disease (GERD). Causes of its development are still not completely understood and genetics factors could play an important role. At our knowledge, there aren’t data regarding the prevalence of BE in first degree relatives of patients with BE. Recently, esophageal capsule endoscopy (ECE) has been proposed as a non invasive investigation of esophageal pathology. Our aims were to assess prospectively the prevalence of BE and GERD in first degree relatives of patients with BE and reflux symptoms and to evaluate the diagnostic yield of ECE in these conditions. Patients and Methods: Between July and October 2008, 14 patients (6 men, mean age 52 8) were enrolled. The inclusion criteria were familial history of one or more first-degree relative with BE (intestinal metaplasia histologically confirmed) and typical reflux syndrome. Patients underwent ECE followed by esophagogastroduodenoscopy (EGD). The endoscopist that performed EGD was blind to the ECE findings, which were assessed by an indipendent observer. EGD findings were considered gold standard. The Los Angeles score and Prague classification were adopted and the ECE findings were compared with those at EGD. Results: All the patients completed the study. Esophagitis and endoscopically suspected esophageal metaplasia (ESEM) were present, at ECE, in 6 and 10 patients, respectively. ESEM was present in 8 of 10 patients at EGD; in all cases intestinal metaplasia was detected at histology. Prevalence of BE in our series was 57%. The sensitivity, specificity, PPV and NPV of ECE for esophagitis were 83%, 88%, 83% and 88%, respectively. The sensitivity, specificity, PPV and NPV of ECE for ESEM were 100%, 67%, 80% and 100%, respectively. Conclusions: This is the first study that involves first degree-relatives of BE patients with reflux symptoms. We found that ECE is highly reliable in detecting ESEM, given its good PPV and optimal NPV, in a selected population with a high a-priori probability of BE. In fact, in our series there was a high prevalence of BE, while esophagitis was less present (42%). BE was detected in about 3% of cases in a typical reflux syndrome series recently investigated in our region. This higher prevalence could be explained with a familial, possibly genetic, component in the pathogenesis in BE. Pending confirmation of these preliminary results, we suggest that ECE could be proposed as a screening test in relatives of BE patients.
www.giejournal.org