- Email: [email protected]
Screening of patients referred for a Barrett's ablation protocol: Findings & implications for patients and providers
"4167 EFFICACY
OF ENDOSCOPIC VARICEAL BAND LIGATION ACCORDING TO THE CHILD-PUGH GRADE Cesar V. Lopes, Julio C. Pereira-Lima, Claudio A. Marroni, Santa Casa Hosp, Porto Alegre Brazil Background: The use of endoscopic variceal ligation (EVL) in the eradication of esophageal varices of Child C cirrhotic patients is controversial. The aim of this study is to report our experience on a consecutive and prospectively collected series of 113 cirrhotics with previous esophageal variceal bleeding treated by EVL and to compare the efficacy of this method among the classes of Child-Pugh. Methods: Between 64/96 and 07/2000, 113 patients were treated (76M/37F;mean age=50.Syr; Child A=50 ,Child B=42, Child C=21). The etiology of cirrhosis was HCV in 42 cases, alcohol in 32, HCV + alcohol in 19, I-IBV in 7 and other etiologies in 13. The mean previous bleeding episodes per patient was 2.1 (1-10). EVL was performed on a two-week basis after the variceal bleeding episode was controlled by sclerotherapy or somatostatin. Results: Varices were eradicated in 80 of 113 patients (71%) after a mean of 3.7 (2-11) sessions. Ten patients abandoned therapy, 4 underwent liver transplantation and 10 presented with carcinoma. Excluding these cases, eradication reached 83%. Among the Child C cirrhotic patients, eradication and rebleeding were 57% (8 of 14 cases) and 50% (7/14), respectively and among Child A/B cirrhotics, eradication and rebleeding were 88% (66/75) and 20% (15/75), respectively [p=0.Ol4; RR=3,57 (1.51-8.45) for eradication and p=0.04; RR=2.5 (1.255.00) for rebleeding]. Overall, after a mean fallow-up of 12.2 (1-43) months, 22 (24.7%) of the 89 followed-up patients rebled. Eleven of the rebleeding episodes occurred before variceal eradication. There were 14 deaths (15.7%), of which l0 were bleeding-related. The mortality among Child C cirrhotics was 43% (6/14) and among Child A/B patients it was 10.7% (8/75) {RR=4.02 (1.65-9.80);p=0.008}. Conclusions: EVL is considerably less effective in terms of eradication, rebleeding and survival in Child C cirrhotic patients. Due to the advanced stage of liver disease in these patients, EVL must be compared with other therapies, before contraindicating this procedure in this group of patients.
"4169
SCREENING O F P A T I E N T S R E F E R R E D F O R A BARRETT'S ABLATION PROTOCOL: F I N D I N G S & IMPLICATIONS F O R PATIENTS AND PROVIDERS. Gareth S. Dulal, Dennis M. Jensen, Wilfred M. Weinstein, Galen Cortina, Andrew F. Ippoliti, Anne Wenzinger, Lisa Chapman, Lana Fontana, UCLA, Los Angeles, CA A diagnosis of Barrett's esophagus (BE) has important medical and social implications. Endoscopic ablation of BE has been reported, but reports do not describe all cases assessed. For patients referred with a diagnosis of BE for possible ablation in a randomized clinical trial (RCT), our PURPOSES were: 1) to compare demographics of randomized vs. excluded groups, 2) to describe reasons for exclusion, & 3) to discuss implications of these results. METHODS All patients referred with a diagnosis of BE for the RCT were evaluated (medical record review, H&F, labs) for possible inclusion by a research coordinator & a study physician prior to endoscopy. Jumbo biopsies of duodenum, stomach, & esophagus (Seattle protocol) were reviewed by an experienced GI pathologist. Z2 & t tests were used to compare groups. RESULTS 93 patients were referred & evaluated. See Table for demographic comparisons of groups. Reasons for exclusion were: refusal (most due to need for multiple study EGDs) 32%, BE length <2cm 13%, BE >7cm 10%, no BE on biopsy 10%, severe co-morbidity 9%, severe stricture 7%, prior anti-reflux surgery 7%, organ transplant 4%, b.x recent major cancer 4%, hx poor compliance 4%, & early gastric cancer on biopsy in 3%. CONCLUSIONS Only 24% of referrals for a RCT of BE ablation qualified for randomization. However, a third of excluded patients benefitted from evaluation because they were found to have no BE, early gastric cancer, shortsegment BE, or severe esophagitis with stricture. Among those excluded, the most common reason was refusal to return for repeat endoscopic treatments. Excluded patients were more likely to be older, female, & without a history of heartburn, smoking, or alcohol use. These results suggest that although exclusion is common, many patients benefit from referral to a specialty center. Funded in part by ADHF, VA HSR, STAR, NIH 1K2402650, Wyeth Ayerst, & CRC M01-RR00865.
"4168
ENDOSCOPIC ARGON-PLASMA COAGULATION (APC) OF BARRETT'S ESOPHAGUS: LONG TERM FOLLOW-UP Luigi Familiari, Marisa Bonica, Pierhiigi Consolo, University of Messina, Messina Italy; Donatella Fichera, Univ of Messina, Messina Italy; Pietro Familiari, University of Messina, Messina Italy Background: Barrett's esophagus predisposes to the development of adenocarcinoma of the esophagus and the esophago-gastric junction. The eradication of Barrett's mucosa can be achieved by many endoscopic therapies: thermo or photocoagulation, mucosectomy ... Argon plasma treatment is a safe and simple method, but there are not many studies of long term follow-up. The aim of this study is the evaluation of APC and PPI treatment of the Barrett's esophagus after a long follow-up period. Methods: 20 patients (18M/2F), mean age 58.3 (29-78)yrs, with histologically demonstrated Barrett's esophagus where treated with APC and PPI. 12 cases presented short Barrett, in 5 cases the length of columnar mucosa reached 34 cm, in 3 patients 5-6 cm. 12 cases presented low-grade dysplasia (all long Barrett and 4 of short). Hiatal hernia was associated in 5 cases, scarred bulb in 2, total gastrectomy in 1 and duodenal ulcer in 1. All patients are treated with APC at a power setting of 60W and 2L/rain . Sessions were repeated every 3 weeks until complete eradication of Barrett and restoration of squamous mucosa. All patients received 40mg daily of Omeprazole during the treatment period and the first 6 months of follow up; 20 mg daily afterwards. In 2 patients 20rag was insufficient to let free of symptoms and was necessary 40mg daily. 1 patient was treated by laparoscopic fundoplicatio. Squamous re-epithelization was confirmed every 6 months after APC treatment by endoscopy and the performance of 4-quadrant biopsies. Results: Complete eradication of Barrett and restoration of squamous mucosa was obtained in all patients after a mean of 1.9 sessions of APC (range 1-3): six patients required only 1 session, nine required 2, and five required 3 sessions. Tolerability was good for all patients; no major complications was observed, but just mild chest-pain in 7 patients. After a mean follow-up of 28 months (6-36) only one case of recurrence was observed, after 6 months, with some islets of cohimnar mucosa: the patient was treated again with 1 session of APC. Conclusions: APC treatment of Barrett's esophagus is simple, efficacious and safe. Reversal of Barrett's mucosa can be achieved by a few endoscopic sessions. But long term followup studies on many patients are necessary to establish the frequency of endoscopic surveillance on the basis of recurrence or dysplasia evolution risk, in spite of APC treatment.
AB158
GASTROINTESTINAL ENDOSCOPY
Included Excluded
N
Age
Male
W h i t e Heartburn
Smoker
Etoh
22 71
54 62"
95% 65%"
86% 72%
50% 20%"
68% 24%*
95% 58%"
"p
"4170 B R U S H CYTOLOGY VIA UNSEDATED ESOPHAGOSCOPY F O R
THE DIAGNOSIS OF BARRETT'S ESOPHAGUS Charles Huh, Michael Henry, Peter E. Darwin, Univ of Maryland, Baltimore, MD Background and Aims: Unsedated endoscopy(UEGD)has been shown to be feasible, well tolerated, and accurate for the diagnosis of upper GI pathology. This technique would seem to be an ideal method to screen for Barrett's. However, to accurately make the diagnosis, pathologic confirmation is required. To date, there have been no studies to evaluate UEGD with brush cytology for screening of Barrett's. The aims of this pilot study were to evaluate whether brush cytology obtained by UEGD was equal to standard biopsy to diagnose Barrett's metaplasia. Methods: Consecutive patients with established Barrett'e esophagus who were undergoing surveillance were asked to participate. Patients without a history or endoscopic evidence of Barrett's esophagus served as the negative controls. UEGD was performed using a pediatric fiber optic endoscope. Cytology was obtained by passing a pediatric brush along the Barrett's mucosa (or normal mucosa in the negative controls) in all four quadrants of the esophagus. The duration of the procedure was recorded. After finishing the procedure, patients were asked to complete a short questionnaire concerning the tolerability of the exam. Conventional EGD with sedation was then performed with serial surveillance biopsies. The cytology specimens were air dried, numbered, and sent to a cytologist, who was blinded to the history, endoscopic findings and biopsy histology. Results: Five patients with Barrett's esophagus and three control patients were recruited. Cytology detected the presence of Barrett's metaplasia in all five study patients. In addition, dysplasia (one high-grade, one low-grade) was detected in two patients which were confirmed by biopsy. This gives a sensitivity, specificity and positive predictive value of 100%. Barrett's metaplasia was not found in any of the control patients. The average duration of the UEGD was 3 minutes and 30 seconds. 4 of 5 patients experienced some gagging, 0 of 5 experienced a sore throat, and 5 of 5 said that they would repeat the procedure. Conclusions: Although the number of patients is small, the results of this study suggest that brush cytology via UEGD is a reliable method for detecting Barrett's metaplasia. A prospective, blinded, and randomized study with a larger number of patients would be required in order to properly evaluate the value of this procedure. Should UEGD with cytology prove reliable for Barrett's diagnosis, then ultimately it could become a valuable screening method in the chronic GERD population.
VOLUME 53, NO. 5, 2001
OF ENDOSCOPIC VARICEAL BAND LIGATION ACCORDING TO THE CHILD-PUGH GRADE Cesar V. Lopes, Julio C. Pereira-Lima, Claudio A. Marroni, Santa Casa Hosp, Porto Alegre Brazil Background: The use of endoscopic variceal ligation (EVL) in the eradication of esophageal varices of Child C cirrhotic patients is controversial. The aim of this study is to report our experience on a consecutive and prospectively collected series of 113 cirrhotics with previous esophageal variceal bleeding treated by EVL and to compare the efficacy of this method among the classes of Child-Pugh. Methods: Between 64/96 and 07/2000, 113 patients were treated (76M/37F;mean age=50.Syr; Child A=50 ,Child B=42, Child C=21). The etiology of cirrhosis was HCV in 42 cases, alcohol in 32, HCV + alcohol in 19, I-IBV in 7 and other etiologies in 13. The mean previous bleeding episodes per patient was 2.1 (1-10). EVL was performed on a two-week basis after the variceal bleeding episode was controlled by sclerotherapy or somatostatin. Results: Varices were eradicated in 80 of 113 patients (71%) after a mean of 3.7 (2-11) sessions. Ten patients abandoned therapy, 4 underwent liver transplantation and 10 presented with carcinoma. Excluding these cases, eradication reached 83%. Among the Child C cirrhotic patients, eradication and rebleeding were 57% (8 of 14 cases) and 50% (7/14), respectively and among Child A/B cirrhotics, eradication and rebleeding were 88% (66/75) and 20% (15/75), respectively [p=0.Ol4; RR=3,57 (1.51-8.45) for eradication and p=0.04; RR=2.5 (1.255.00) for rebleeding]. Overall, after a mean fallow-up of 12.2 (1-43) months, 22 (24.7%) of the 89 followed-up patients rebled. Eleven of the rebleeding episodes occurred before variceal eradication. There were 14 deaths (15.7%), of which l0 were bleeding-related. The mortality among Child C cirrhotics was 43% (6/14) and among Child A/B patients it was 10.7% (8/75) {RR=4.02 (1.65-9.80);p=0.008}. Conclusions: EVL is considerably less effective in terms of eradication, rebleeding and survival in Child C cirrhotic patients. Due to the advanced stage of liver disease in these patients, EVL must be compared with other therapies, before contraindicating this procedure in this group of patients.
"4169
SCREENING O F P A T I E N T S R E F E R R E D F O R A BARRETT'S ABLATION PROTOCOL: F I N D I N G S & IMPLICATIONS F O R PATIENTS AND PROVIDERS. Gareth S. Dulal, Dennis M. Jensen, Wilfred M. Weinstein, Galen Cortina, Andrew F. Ippoliti, Anne Wenzinger, Lisa Chapman, Lana Fontana, UCLA, Los Angeles, CA A diagnosis of Barrett's esophagus (BE) has important medical and social implications. Endoscopic ablation of BE has been reported, but reports do not describe all cases assessed. For patients referred with a diagnosis of BE for possible ablation in a randomized clinical trial (RCT), our PURPOSES were: 1) to compare demographics of randomized vs. excluded groups, 2) to describe reasons for exclusion, & 3) to discuss implications of these results. METHODS All patients referred with a diagnosis of BE for the RCT were evaluated (medical record review, H&F, labs) for possible inclusion by a research coordinator & a study physician prior to endoscopy. Jumbo biopsies of duodenum, stomach, & esophagus (Seattle protocol) were reviewed by an experienced GI pathologist. Z2 & t tests were used to compare groups. RESULTS 93 patients were referred & evaluated. See Table for demographic comparisons of groups. Reasons for exclusion were: refusal (most due to need for multiple study EGDs) 32%, BE length <2cm 13%, BE >7cm 10%, no BE on biopsy 10%, severe co-morbidity 9%, severe stricture 7%, prior anti-reflux surgery 7%, organ transplant 4%, b.x recent major cancer 4%, hx poor compliance 4%, & early gastric cancer on biopsy in 3%. CONCLUSIONS Only 24% of referrals for a RCT of BE ablation qualified for randomization. However, a third of excluded patients benefitted from evaluation because they were found to have no BE, early gastric cancer, shortsegment BE, or severe esophagitis with stricture. Among those excluded, the most common reason was refusal to return for repeat endoscopic treatments. Excluded patients were more likely to be older, female, & without a history of heartburn, smoking, or alcohol use. These results suggest that although exclusion is common, many patients benefit from referral to a specialty center. Funded in part by ADHF, VA HSR, STAR, NIH 1K2402650, Wyeth Ayerst, & CRC M01-RR00865.
"4168
ENDOSCOPIC ARGON-PLASMA COAGULATION (APC) OF BARRETT'S ESOPHAGUS: LONG TERM FOLLOW-UP Luigi Familiari, Marisa Bonica, Pierhiigi Consolo, University of Messina, Messina Italy; Donatella Fichera, Univ of Messina, Messina Italy; Pietro Familiari, University of Messina, Messina Italy Background: Barrett's esophagus predisposes to the development of adenocarcinoma of the esophagus and the esophago-gastric junction. The eradication of Barrett's mucosa can be achieved by many endoscopic therapies: thermo or photocoagulation, mucosectomy ... Argon plasma treatment is a safe and simple method, but there are not many studies of long term follow-up. The aim of this study is the evaluation of APC and PPI treatment of the Barrett's esophagus after a long follow-up period. Methods: 20 patients (18M/2F), mean age 58.3 (29-78)yrs, with histologically demonstrated Barrett's esophagus where treated with APC and PPI. 12 cases presented short Barrett, in 5 cases the length of columnar mucosa reached 34 cm, in 3 patients 5-6 cm. 12 cases presented low-grade dysplasia (all long Barrett and 4 of short). Hiatal hernia was associated in 5 cases, scarred bulb in 2, total gastrectomy in 1 and duodenal ulcer in 1. All patients are treated with APC at a power setting of 60W and 2L/rain . Sessions were repeated every 3 weeks until complete eradication of Barrett and restoration of squamous mucosa. All patients received 40mg daily of Omeprazole during the treatment period and the first 6 months of follow up; 20 mg daily afterwards. In 2 patients 20rag was insufficient to let free of symptoms and was necessary 40mg daily. 1 patient was treated by laparoscopic fundoplicatio. Squamous re-epithelization was confirmed every 6 months after APC treatment by endoscopy and the performance of 4-quadrant biopsies. Results: Complete eradication of Barrett and restoration of squamous mucosa was obtained in all patients after a mean of 1.9 sessions of APC (range 1-3): six patients required only 1 session, nine required 2, and five required 3 sessions. Tolerability was good for all patients; no major complications was observed, but just mild chest-pain in 7 patients. After a mean follow-up of 28 months (6-36) only one case of recurrence was observed, after 6 months, with some islets of cohimnar mucosa: the patient was treated again with 1 session of APC. Conclusions: APC treatment of Barrett's esophagus is simple, efficacious and safe. Reversal of Barrett's mucosa can be achieved by a few endoscopic sessions. But long term followup studies on many patients are necessary to establish the frequency of endoscopic surveillance on the basis of recurrence or dysplasia evolution risk, in spite of APC treatment.
AB158
GASTROINTESTINAL ENDOSCOPY
Included Excluded
N
Age
Male
W h i t e Heartburn
Smoker
Etoh
22 71
54 62"
95% 65%"
86% 72%
50% 20%"
68% 24%*
95% 58%"
"p
"4170 B R U S H CYTOLOGY VIA UNSEDATED ESOPHAGOSCOPY F O R
THE DIAGNOSIS OF BARRETT'S ESOPHAGUS Charles Huh, Michael Henry, Peter E. Darwin, Univ of Maryland, Baltimore, MD Background and Aims: Unsedated endoscopy(UEGD)has been shown to be feasible, well tolerated, and accurate for the diagnosis of upper GI pathology. This technique would seem to be an ideal method to screen for Barrett's. However, to accurately make the diagnosis, pathologic confirmation is required. To date, there have been no studies to evaluate UEGD with brush cytology for screening of Barrett's. The aims of this pilot study were to evaluate whether brush cytology obtained by UEGD was equal to standard biopsy to diagnose Barrett's metaplasia. Methods: Consecutive patients with established Barrett'e esophagus who were undergoing surveillance were asked to participate. Patients without a history or endoscopic evidence of Barrett's esophagus served as the negative controls. UEGD was performed using a pediatric fiber optic endoscope. Cytology was obtained by passing a pediatric brush along the Barrett's mucosa (or normal mucosa in the negative controls) in all four quadrants of the esophagus. The duration of the procedure was recorded. After finishing the procedure, patients were asked to complete a short questionnaire concerning the tolerability of the exam. Conventional EGD with sedation was then performed with serial surveillance biopsies. The cytology specimens were air dried, numbered, and sent to a cytologist, who was blinded to the history, endoscopic findings and biopsy histology. Results: Five patients with Barrett's esophagus and three control patients were recruited. Cytology detected the presence of Barrett's metaplasia in all five study patients. In addition, dysplasia (one high-grade, one low-grade) was detected in two patients which were confirmed by biopsy. This gives a sensitivity, specificity and positive predictive value of 100%. Barrett's metaplasia was not found in any of the control patients. The average duration of the UEGD was 3 minutes and 30 seconds. 4 of 5 patients experienced some gagging, 0 of 5 experienced a sore throat, and 5 of 5 said that they would repeat the procedure. Conclusions: Although the number of patients is small, the results of this study suggest that brush cytology via UEGD is a reliable method for detecting Barrett's metaplasia. A prospective, blinded, and randomized study with a larger number of patients would be required in order to properly evaluate the value of this procedure. Should UEGD with cytology prove reliable for Barrett's diagnosis, then ultimately it could become a valuable screening method in the chronic GERD population.
VOLUME 53, NO. 5, 2001