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Su1022 What Is the Histology of Subsquamous Intestinal Metaplasia (SSIM) in Patients With Prior Radiofrequency Ablation (RFA) for Treatment of Barrett's Esophagus (BE)? Results From the U.S. RFA Registry
Su1023
Background: Temporary fecal diversion has been used to allow severe perianal Crohn's disease (CD) to heal. However, there are limited data on rates of successful reconnection and most series precede the biologic era. We defined the rate of successful ostomy reversal and identified factors associated with restoring intestinal continuity in a CD cohort with perianal involvement who underwent fecal diversion. We also evaluated temporal trends in perianal interventions for CD from two tertiary referral centers. Methods: We retrospectively studied all patients from a cohort composed of patients with CD and perianal involvement who underwent fecal diversion between 1991 and 2012. Patient demographics, medication use, onset and extent of disease and surgical interventions were abstracted. Time to restoration of intestinal continuity was determined, as were potential predictive factors for ostomy reversal. Using an institutional patient registry, we also examined temporal trends in the proportion of perianal CD patients undergoing diverting ostomy or management with setons/ EUA/fistulotomy between 2000-2011. Results: We identified a total of 49 CD patients with perianal involvement who underwent fecal diversion. The mean follow up period from diversion to last visit was 6 years (range: 0-20 yrs). The average time from diagnosis to onset of perianal disease was 8 years (range: 0-29 yrs). 10 patients (20%) were male. 41/ 49 (84%) had exposure to biologic therapy. 15/49 (31%) re-established intestinal continuity during the study follow-up period (Figure 1). Age at diagnosis, use of infliximab before or after diversion, extent of disease, smoking status and duration of perianal disease before diversion did not predict restoration of intestinal continuity in diverted CD patients (all p.0.05). By the end of the follow-up period, 11/15 (73%) of patients who had re-established intestinal continuity required an additional procedure to divert the fecal stream. Examining overall temporal trends in surgical procedures, the proportion of CD patients requiring perianal surgical interventions declined between 2000 and 2011 with a steeper decline in the rate of diverting procedures (Figure 2). Conclusion: Despite increasing use of anti-TNF agents, severe perianal CD remains a challenging problem. In this population of CD patients with perianal disease who require fecal diversion, the likelihood of sustained intestinal continuity remains low, despite greater use of biologic therapy. However, there has been a temporal decline in the rate of surgical interventions required for perianal fistulizing Crohn's disease from 2000-2011.
Su1022 What Is the Histology of Subsquamous Intestinal Metaplasia (SSIM) in Patients With Prior Radiofrequency Ablation (RFA) for Treatment of Barrett's Esophagus (BE)? Results From the U.S. RFA Registry Kelly E. Hathorn, William J. Bulsiewicz, Ronald E. Pruitt, Gary W. Chmielewski, Ryan D. Madanick, F Scott Corbett, Richard I. Rothstein, Charles J. Lightdale, George Triadafilopoulos, Nicholas J. Shaheen Background: While the esophagus may appear endoscopically normal following RFA, there may be underlying subsquamous intestinal metaplasia (SSIM) that can only be diagnosed by biopsy and pathologic review. Beyond case reports, little is known regarding the severity of the histology of this SSIM. We assessed histological findings of SSIM from a national patient treatment registry. Methods: The U.S. RFA Registry is a prospective study of RFA treatment at 148 institutions. Information collected in the registry includes demographic data, histology prior to treatment, endoscopic findings, number of RFA treatment sessions, ablation outcomes, and complications. Our study cohort consisted of all patients treated with RFA who underwent subsequent biopsy. SSIM was defined as metaplastic columnar tissue found beneath an overlying layer of intact squamous epithelium. Specific information extracted from the database included frequency of the diagnosis, the histologic grade of SSIM disease at the time of diagnosis (intestinal metaplasia (IM), low-grade dysplasia (LGD), high-grade dysplasia (HGD), intramucosal carcinoma (IMC), or invasive adenocarcinoma), as well as the pre-RFA treatment histology (IM, LGD, HGD, IMC, or adenocarcinoma). Baseline biopsies to evaluate for SSIM prior to RFA were not performed. Results: At least one biopsy session was performed in 4691 of 5530 (85%) patients treated with RFA, among whom 410 (8.7%) were diagnosed with SSIM at some point during 6134 surveillance biopsy sessions. Of subjects found to have SSIM, 61% (249/410) were noted on the first biopsy session. 269 patients had non-dysplastic SSIM (5.7%), 52 had IM with LGD (1.1%), 37 had IM with HGD (0.8%), 17 had IM with IMC (0.4%) and 14 had invasive adenocarcinoma (0.3%) (see table). On average, SSIM was identified after 2.5 RFA sessions (0.8 circumferential, 1.7 focal), 1.8 biopsy sessions, and 12.3±12.6 months after treatment was initiated. When compared to pre-treatment histology, 170 patients (41%) had improved histologic findings in their SSIM, 194 patients (47%) had identical histologic findings, and 46 patients (11%) had worse histologic findings. Progression to HGD or worse from baseline IM or LGD histology occurred in 16 of 3505 patients (0.5%). Advanced SSIM (HGD or worse) was more frequent among patients with HGD or worse at baseline (4.4%; 52/1186). Conclusions: 8.7% of patients treated with RFA for BE were found to have SSIM at some point in followup surveillance. Because baseline biopsies for SSIM were not performed, the proportion of this group which harbored prevalent SSIM before RFA treatment is unknown. The majority of cases showed either improved or identical histology when compared to pre-treatment histology. However, a small number had more severe disease, demonstrating the utility of ongoing surveillance in this population.
Proportion of Crohn's Disease Patients with Perianal Involvement Who Remained Diverted During Follow up
Temporal Trend in Surgical Interventions for Perianal Crohn's Disease from 2000-2011
S-377
AGA Abstracts
AGA Abstracts
Restoration of Intestinal Continuity Following Fecal Diversion for Perianal Crohn's Disease Jenny Sauk, Deanna D. Nguyen, Vijay Yajnik, Ashwin N. Ananthakrishnan
Background: Temporary fecal diversion has been used to allow severe perianal Crohn's disease (CD) to heal. However, there are limited data on rates of successful reconnection and most series precede the biologic era. We defined the rate of successful ostomy reversal and identified factors associated with restoring intestinal continuity in a CD cohort with perianal involvement who underwent fecal diversion. We also evaluated temporal trends in perianal interventions for CD from two tertiary referral centers. Methods: We retrospectively studied all patients from a cohort composed of patients with CD and perianal involvement who underwent fecal diversion between 1991 and 2012. Patient demographics, medication use, onset and extent of disease and surgical interventions were abstracted. Time to restoration of intestinal continuity was determined, as were potential predictive factors for ostomy reversal. Using an institutional patient registry, we also examined temporal trends in the proportion of perianal CD patients undergoing diverting ostomy or management with setons/ EUA/fistulotomy between 2000-2011. Results: We identified a total of 49 CD patients with perianal involvement who underwent fecal diversion. The mean follow up period from diversion to last visit was 6 years (range: 0-20 yrs). The average time from diagnosis to onset of perianal disease was 8 years (range: 0-29 yrs). 10 patients (20%) were male. 41/ 49 (84%) had exposure to biologic therapy. 15/49 (31%) re-established intestinal continuity during the study follow-up period (Figure 1). Age at diagnosis, use of infliximab before or after diversion, extent of disease, smoking status and duration of perianal disease before diversion did not predict restoration of intestinal continuity in diverted CD patients (all p.0.05). By the end of the follow-up period, 11/15 (73%) of patients who had re-established intestinal continuity required an additional procedure to divert the fecal stream. Examining overall temporal trends in surgical procedures, the proportion of CD patients requiring perianal surgical interventions declined between 2000 and 2011 with a steeper decline in the rate of diverting procedures (Figure 2). Conclusion: Despite increasing use of anti-TNF agents, severe perianal CD remains a challenging problem. In this population of CD patients with perianal disease who require fecal diversion, the likelihood of sustained intestinal continuity remains low, despite greater use of biologic therapy. However, there has been a temporal decline in the rate of surgical interventions required for perianal fistulizing Crohn's disease from 2000-2011.
Su1022 What Is the Histology of Subsquamous Intestinal Metaplasia (SSIM) in Patients With Prior Radiofrequency Ablation (RFA) for Treatment of Barrett's Esophagus (BE)? Results From the U.S. RFA Registry Kelly E. Hathorn, William J. Bulsiewicz, Ronald E. Pruitt, Gary W. Chmielewski, Ryan D. Madanick, F Scott Corbett, Richard I. Rothstein, Charles J. Lightdale, George Triadafilopoulos, Nicholas J. Shaheen Background: While the esophagus may appear endoscopically normal following RFA, there may be underlying subsquamous intestinal metaplasia (SSIM) that can only be diagnosed by biopsy and pathologic review. Beyond case reports, little is known regarding the severity of the histology of this SSIM. We assessed histological findings of SSIM from a national patient treatment registry. Methods: The U.S. RFA Registry is a prospective study of RFA treatment at 148 institutions. Information collected in the registry includes demographic data, histology prior to treatment, endoscopic findings, number of RFA treatment sessions, ablation outcomes, and complications. Our study cohort consisted of all patients treated with RFA who underwent subsequent biopsy. SSIM was defined as metaplastic columnar tissue found beneath an overlying layer of intact squamous epithelium. Specific information extracted from the database included frequency of the diagnosis, the histologic grade of SSIM disease at the time of diagnosis (intestinal metaplasia (IM), low-grade dysplasia (LGD), high-grade dysplasia (HGD), intramucosal carcinoma (IMC), or invasive adenocarcinoma), as well as the pre-RFA treatment histology (IM, LGD, HGD, IMC, or adenocarcinoma). Baseline biopsies to evaluate for SSIM prior to RFA were not performed. Results: At least one biopsy session was performed in 4691 of 5530 (85%) patients treated with RFA, among whom 410 (8.7%) were diagnosed with SSIM at some point during 6134 surveillance biopsy sessions. Of subjects found to have SSIM, 61% (249/410) were noted on the first biopsy session. 269 patients had non-dysplastic SSIM (5.7%), 52 had IM with LGD (1.1%), 37 had IM with HGD (0.8%), 17 had IM with IMC (0.4%) and 14 had invasive adenocarcinoma (0.3%) (see table). On average, SSIM was identified after 2.5 RFA sessions (0.8 circumferential, 1.7 focal), 1.8 biopsy sessions, and 12.3±12.6 months after treatment was initiated. When compared to pre-treatment histology, 170 patients (41%) had improved histologic findings in their SSIM, 194 patients (47%) had identical histologic findings, and 46 patients (11%) had worse histologic findings. Progression to HGD or worse from baseline IM or LGD histology occurred in 16 of 3505 patients (0.5%). Advanced SSIM (HGD or worse) was more frequent among patients with HGD or worse at baseline (4.4%; 52/1186). Conclusions: 8.7% of patients treated with RFA for BE were found to have SSIM at some point in followup surveillance. Because baseline biopsies for SSIM were not performed, the proportion of this group which harbored prevalent SSIM before RFA treatment is unknown. The majority of cases showed either improved or identical histology when compared to pre-treatment histology. However, a small number had more severe disease, demonstrating the utility of ongoing surveillance in this population.
Proportion of Crohn's Disease Patients with Perianal Involvement Who Remained Diverted During Follow up
Temporal Trend in Surgical Interventions for Perianal Crohn's Disease from 2000-2011
S-377
AGA Abstracts
AGA Abstracts
Restoration of Intestinal Continuity Following Fecal Diversion for Perianal Crohn's Disease Jenny Sauk, Deanna D. Nguyen, Vijay Yajnik, Ashwin N. Ananthakrishnan