- Email: [email protected]
Supraglottic laryngeal stenosis-a rare extraesophageal manifestation of gerd
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Abstracts
necrosis and perforation of the intestinal wall. The diagnosis of amebic colitis rests on the demonstration of E. histolytica in the stool or colonic mucosa. The mainstay of treatment remains metronidazole, followed by a luminal agent (paromomycin, iodoquinol, or diloxanide furoate) to eradicate colonization. Amebic colitis rarely presents with continuous mucosal inflammation, making it indistinguishable from UC. Since the erroneous diagnosis of UC can lead to disastrous complications, it is imperative to exclude amebic colitis prior to undertaking steroid therapy, especially in patients with a prior history of travel to or residence in areas endemic for E. histolytica. Our case illustrates the need for high index of suspicion in immigrants and visitors from developing world for amebiasis in the differential diagnosis of pancolitis.
651 NEW APPROACH IN THE MANAGEMENT OF PROXIMALLY MIGRATED STENT WITH AN OBSTRUCTING ANTI-REFLUX VALVE Sanjay Nayyar, M.D., Archana Verma, M.D., Benjamin T. Go, M.D.*, Gonzalo Pandolfi, M.D., Frida Abrahamian, M.D., Bashar M. Attar, M.D. Cook County Hospital, Chicago, IL. Esophageal cancers are usually diagnosed at a late stage requiring palliative treatment. The use of self-expandable metallic stents (SEMS) have produced impressive results in improving dysphagia. Even with the increasing use of SEMS, there are still complications. The most important include esophageal perforation, hemorrhage, stent migration and fistulization. We are reporting a case of proximal migration of SEMS with an antireflux valve (ARV) causing complete occlusion and management. The patient is a 60 year-old male who was diagnosed 4 weeks prior with an unresectable squamous carcinoma of the distal esophagus at another hospital. An esophageal Z-stent with dua ARV was placed. Patient presented to our hospital 2 weeks after placement with inability to handle his secretions. EGD performed showed the stent located from 20 to 32 cm, with complete obstruction by the ARV. Attempts to remove the stent were unsuccessful due to siginificant inflammatory reaction at the proximal end of the stent but distal to the UES. A needle knife sphincterotome was used to carefully cut through the ARV to allow the passage of an ERCP catheter into the stomach. The ARV was then removed by piecemeal fashion with snare electrocautery to allow deployment of a second SEMS. The tumor extended from 34 to 41 cm with the GE junction at 40 cm and was dilated with a 12 mm balloon. A 14 cm Z-stent with ARV was deployed through the first stent with the proximal end at 27 cm and the distal end at 41 cm. Post-procedure gastrograffin showed ideal stent placement with passage of contrast into the stomach. Patient was discharged after 2 days without complications. While most stent migrations occur distally, they can rarely migrate proximally and be complicated by the ARV. In cases where the stent cannot be removed endoscopically, removal of the ARV can be done with a snare electrocautery to allow deployment of a second stent. The same technique can be utilized with a double channel scope to shorten an ARV after SEMS deployment.
652 GASTRIC NECROSIS: A COMPLICATION OF GASTRIC BANDING Gerald Fruchter, M.D.*, Vlado Simko, M.D., Hatem Shoukeir, M.D., Hueldine Webb, M.D., Ayse Aytaman, M.D. VA NY Harbor HCS, Brooklyn, NY. Background: Morbid obesity is a growing health problem in the United States. Patients, who fail conservative measures at weight loss, are potential candidates for bariatric surgery. Current weight reduction surgery techniques include gastric restriction procedures, gastric bypass, and biliopancreatic bypass. We report a rare, potentially lethal, complication of gastric banding: gastric necrosis necessitating emergent laparotomy and gastrectomy.
AJG – Vol. 98, No. 9, Suppl., 2003
Case Report: A 55 year-old male with history of morbid obesity presented with 5 days of epigastric pain, progressive dysphagia, and vomiting. He had undergone a laparoscopic gastric banding 7 years prior with subsequent loss of 150lbs. Upon presentation, the patient was in no distress, weight 187lbs with stable vital signs. Abdominal exam revealed a soft, nondistended abdomen with mild epigastric tenderness, no guarding or rebound with a LUQ subcutaneous reservoir. The WBC was 9.2. CXR and abdominal films were unremarkable. Esophagogram showed marked constriction at the level of the gastric band encircling the fundus with significant hang-up of barium. On the second day of hospital stay, WBC rose to 29.7; exam was unchanged. An abdominal CT scan was unrevealing except for a left lung base infiltrate. Antibiotics were initiated. The following day, patient’s WBC rose to 35.2 with an unchanged exam. Upper endoscopy revealed a distended proximal gastric pouch filled with coffee ground liquid and a large area of confluent ischemia covered by eschar as well as multiple small islands of ischemia. At surgery, there were multiple areas of necrosis in the serosal surface of the dilated fundus proximal to the strangulating ring as well as evidence of peritonitis. The stomach contained over 3 liters of sloughed gastric lining. A near total gastrectomy with roux-en-y gastrojejunostomy was performed. Pathological exam revealed transmural hemorrhagic necrosis of the fundus with marked thinning and impending perforation. The patient had an uneventful post-op course. Discussion: Bariatric surgery is effective in treating morbid obesity. For gastric banding, revision is occasionally needed to address gastric slippage, stenosis, as well as stomal obstruction. In our case, gastric banding induced strangulation with resultant full-thickness gastric necrosis and peritonitis. Clinicians involved in management of patients who undergo bariatric surgery need to be aware of the potentially serious consequences inherent in this form of surgery.
653 SUPRAGLOTTIC LARYNGEAL STENOSIS-A RARE EXTRAESOPHAGEAL MANIFESTATION OF GERD Sailaja M. Cheruku, M.D., John O’Brien, M.D.*, Carl Malone, M.D. Southern Illinois University School of Medicine, Springfield, IL. A 60 year-old caucasian female admitted to hospital for progressive, severe shortness of breath, over the past 2–3 weeks. She was sleeping upright in a chair secondary to orthopnea. She has no history of recent fever or acute illness. Past medical history included chronic heart burn, hypertension and obesity. She denied tobacco, alcohol and illicit drug use. She took over the counter antacids for heart burn. On exam, she had audible inspiratory stridor and room air oxygen saturation was 80%. An urgent transnasal fiberoptic laryngoscopy showed inability to visualize true vocal cords and a large 2⫻3 cm mass along the right aryepiglottic fold extending back to posterior commissure completely obstructing the view of her glottis. The impression was supraglottic mass obstructing the air way. She underwent emergency tracheostomy and direct laryngoscopic biopsy of the mass. Histology showed severe inflammation with granulation tissue and no evidence of malignancy. Laboratory evaluation of anti nuclear antibody, anti neutrophil cytoplasmic antibody and angiotensin converting enzyme levels were normal. Her sedimentation rate was 22. A CT Scan of neck showed normal appearance of true vocal cords and severe supraglottic stenosis. In consideration of acid reflux induced ulceration, an upper endoscopy was performed, which demonstrated a hiatal hernia, normal esophagus, stomach and duodenum. She was given Pantoprazole twice daily and discharged home to follow up as out patient, as her post operative course was uneventful. Ten weeks after treatment with pantoprazole, she was evaluated with videostroboscopy and fiberoptic nasopharyngolaryngoscopy, which demonstrated significant decrease in supraglottic swelling and inflammation. She denied any episodes of acid reflux. Despite discussions regarding surgery for acid reflux, the patient declined surgery. She is currently taking once a day pantoprazole. The Plan is to do supraglottic laryngectomy and removal of tracheostomy tube. Common otolaryngologic manifestations of GERD include cough, sore throat, hoarseness, laryngitis, chronic sinusitis, vocal cord nodules, globus, subglottic stenosis and rarely
AJG – September, Suppl., 2003
laryngeal cancer. So this is an extremely rare case of “supraglottic laryngeal stenosis” from GERD. Majority of patiens lack GERD symptoms and have low prevelance of esophagitis. An emperic trial of twice daily PPI for a minimum of 3 months is the preferred diagnostic and treatment approach. 654 ENDOSCOPIC THERAPY OF EARLY GASTRIC CANCER Robert P. Yatto, M.D.*, Elizabeth Petty, M.D., James Barnwell, M.D. Cumberland Medical Center, Crossville, TN. A 67 year-old white female was referred for evaluation of anemia and occult GI bleeding. An EGD revealed a polypoid pre-pyloric lesion that was removed by snare. Histopathology revealed well differentiated adenocarcinoma that did not arise from an underlying adenoma. A repeat endoscopy was done to remove tissue at the base by endoscopic mucosal resection (EMR). Three injections of 7–10 cc of saline were used to lift the base from the submucosa. No residual cancer was seen in the mucosa or submucosa of the base tissue removed during EMR.. Subsequent endoscopic ultrasound was unremarkable for gastric wall or regional lymph node abnormalties. The Japanese classification of this lesion is Type I-protruded. Mucosal cancer is seldom associated with lymph node metastases, whereas submucosal cancer has lymph node metastatic rates of 10 – 40%. It is the possibilty of lymph node invasion that is the most serious limitation of EMR. Surgical series of resected early gastric cancer demonstrate that lymph node involvement can be correlated to the diameter and depth of the superficial gastric tumor, in addition to histology. It can be stated that EMR is indicated in the resection of superficial early gastric cancer when the cancer is well differentiated, limited to the mucosa, and less than 20 mm in diameter. While such lesions are often found in Japan, only four have been reported in the US. This represents the first such lesion treated in a community hospital. This aggressive form of endoscopic therapy is safe and effective and avoids surgery and it’s associated morbidity and mortality. It is attractive because of a demand for minimally invasive procedures in the US, and because the rare association of these lesions with lymph node metastases and long term studies showing EMR patient outcomes similar to surgery.
OUTCOMES RESEARCH 655 THE IMPACT OF TEACHING SURGICAL RESIDENTS ON COLONOSCOPIC PROCEDURE TIME AND SEDATION USED Nirmal S. Mann, M.D.*, Joseph W. Leung, M.D. U.C. Davis and VAMC Martinez, Martinez, CA. Introduction: From July 1, 1999 to November 15, 2002, one of the faculty GI Endoscopists (NSM) was involved in the performance of 1062 colonoscopic procedures. He performed them either alone (Group I) or while teaching a general surgery resident (Group II). Aims: To compare the procedure time (MPT) and the amount of sedation (S) used between Groups I & II. Methods: Records of patients on these 1062 cases were evaluated. The records were evaluated for age, gender, procedure time, amount of Midzolam and Fentanyl used, quality of preparation, diagnoses after endoscopy. The frequency of faculty intervention (FI) to complete the procedure was noted. The results are expressed as mean ⫾ standard error of the mean. The means were compared by t-test and the percentages were compared using Chi square test. Results: There were 829 patients in Group I and 233 patients in Group II. There were 800 (96.5%) men and 29 women (3.5%) in Group I and 225 men (96.5%) and 8 (3.5%) women in Group II. The mean age in Group I was 60.3 ⫾ 4.4 years (range 30-92) and it was 62.7 ⫾ 5.8 years (range 30-91) in Group II. The preparation was good or fair in 755 (91%) and poor in 64 (9%) patients in Group I; it was good or fair in 207 (89%) and poor in 26 (11%) patients in Group II. The diagnoses in Group I were: Normal
Abstracts
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259 (31.2%), Diverticulosis alone 262 (31.6%); Diverticulosis plus polyps and/or cancer 133 (16.0%); polyps or cancer alone 106 (12.7%) and others 69 (8.3%). The figures for Group II are 66 (28.3%), 73 (31.3%); 37 (15.8%) 44 (18.8%) and 13 (5.5%). The MPT for Group I was 17.4 ⫾ 3.7 minutes (range 5– 60). The MPT for Group II was 27.8 ⫾ 5.6 minutes (range 6 –72). The mean amount of Midzolam used in Group I was 1.9 ⫾ 0.2 mgms (range 0-6); for Group II it was 2.5 ⫾ 0.3 mgms (range 0 – 6). The mean amount of Fentanyl for Group I was 81.3 ⫾ 6.4 micrograms range (0 –250); for Group II it was 106.4 ⫾ 8.2 micrograms (range 0 –250). FI occurred in 62 cases (26.6%) in Group II. The MPT and the S used was significantly increased in Group II patients (p⬍0.05); in other respects e.g. age, gender distribution, quality of colonic preparation and post procedure diagnoses the two group were similar (p⬎0.05). Conclusions: The colonoscopic procedure time is significantly increased when the faculty teaches colonoscopy to surgical residents and seems to increase the need for sedation, which may be a reflection of increased procedure time.
656 A CLINICAL SURVEY COMPARING THE EFFECTIVENESS OF ESOMEPRAZOLE AND PANTOPRAZOLE TO TRADITIONAL PPIS (OMEPRAZOLE AND LANSOPRAZOLE) IN RELIEVING SEVERE HEARTBURN Mohammad Farivar, M.D.*, Alexander S. Farivar, M.D., Robert S. Farivar, M.D. Harvard Medical School, Boston, MA; University of Washington Medical Center, Seattle, WA and Brigham & Women’s Hospital. Harvard Medical School, Boston, MA. Purpose: It is generally believed that iso-potent doses of proton pump inhibitors (PPIs) are equally effective in relieving heartburn. This survey was done to test the efficacy of esomeprazole (Nexium) and pantoprazole ( Protonix) to the traditional PPIs, lansoprazole (Prevacid) and omeprazole (Prilosec), in providing heartburn relief. Methods: Over a three-month period 27 consecutive patients (16 females and 11 males, aged 25– 80 years) with a history of frequent daily and nightly heartburn were included in this study. Index endoscopy had revealed erosive esophagitis in 13 patients prior to initiation of PPI treatment. All patients were asked to discontinue their regimen of lansoprazole (30 mg) or omeprazole (20 – 40 mg), and to take esomeprazole (40 mg), followed by pantoprazole (40 mg) (or vice versa) for one month. Patients were given a survey asking them to compare the effectiveness of their established regimen of omeprazole or lansoprazole to equivalent doses of pantoprazole and esomeprazole. All surveys were completed and returned. Daily Heartburn was graded from 1 (not often) to 5 (very often) during both day and night. Patient satisfaction with medication was graded from 1 (not satisfied) to 5 (very satisfied). Results: Average heartburn score prior to PPI treatment was 4.61 during the day and 4.06 at night. All patients had been on varying doses of omeprazole and lansoprazole for years with significant (p⬍0.01) heartburn score improvement (1.37 during the day and 1.55 at night). On esomeprazole, heartburn score improved to 1.29 during the day and 1.33 at night. On pantoprazole, heartburn score increased significantly (p⬍0.01) to 3.48 during the day and 3.10 at night. Heartburn score changes with all PPIs represent statistically significant improvement comparing to no PPI treatment. Similarly, satisfaction scores were lowest at 2.06 with pantoprazole and highest at 4.44 with esomeprazole. Conclusions: When comparing pantoprazole and esomeprazole to traditional PPIs, esomeprazole subjectively provided slightly better heartburn relief, but was not statistically significant. Pantoprazole was significantly worse in providing heartburn relief compared to the other PPIs. Further surveys will need to be performed as our experience with these newer PPIs increases.
Abstracts
necrosis and perforation of the intestinal wall. The diagnosis of amebic colitis rests on the demonstration of E. histolytica in the stool or colonic mucosa. The mainstay of treatment remains metronidazole, followed by a luminal agent (paromomycin, iodoquinol, or diloxanide furoate) to eradicate colonization. Amebic colitis rarely presents with continuous mucosal inflammation, making it indistinguishable from UC. Since the erroneous diagnosis of UC can lead to disastrous complications, it is imperative to exclude amebic colitis prior to undertaking steroid therapy, especially in patients with a prior history of travel to or residence in areas endemic for E. histolytica. Our case illustrates the need for high index of suspicion in immigrants and visitors from developing world for amebiasis in the differential diagnosis of pancolitis.
651 NEW APPROACH IN THE MANAGEMENT OF PROXIMALLY MIGRATED STENT WITH AN OBSTRUCTING ANTI-REFLUX VALVE Sanjay Nayyar, M.D., Archana Verma, M.D., Benjamin T. Go, M.D.*, Gonzalo Pandolfi, M.D., Frida Abrahamian, M.D., Bashar M. Attar, M.D. Cook County Hospital, Chicago, IL. Esophageal cancers are usually diagnosed at a late stage requiring palliative treatment. The use of self-expandable metallic stents (SEMS) have produced impressive results in improving dysphagia. Even with the increasing use of SEMS, there are still complications. The most important include esophageal perforation, hemorrhage, stent migration and fistulization. We are reporting a case of proximal migration of SEMS with an antireflux valve (ARV) causing complete occlusion and management. The patient is a 60 year-old male who was diagnosed 4 weeks prior with an unresectable squamous carcinoma of the distal esophagus at another hospital. An esophageal Z-stent with dua ARV was placed. Patient presented to our hospital 2 weeks after placement with inability to handle his secretions. EGD performed showed the stent located from 20 to 32 cm, with complete obstruction by the ARV. Attempts to remove the stent were unsuccessful due to siginificant inflammatory reaction at the proximal end of the stent but distal to the UES. A needle knife sphincterotome was used to carefully cut through the ARV to allow the passage of an ERCP catheter into the stomach. The ARV was then removed by piecemeal fashion with snare electrocautery to allow deployment of a second SEMS. The tumor extended from 34 to 41 cm with the GE junction at 40 cm and was dilated with a 12 mm balloon. A 14 cm Z-stent with ARV was deployed through the first stent with the proximal end at 27 cm and the distal end at 41 cm. Post-procedure gastrograffin showed ideal stent placement with passage of contrast into the stomach. Patient was discharged after 2 days without complications. While most stent migrations occur distally, they can rarely migrate proximally and be complicated by the ARV. In cases where the stent cannot be removed endoscopically, removal of the ARV can be done with a snare electrocautery to allow deployment of a second stent. The same technique can be utilized with a double channel scope to shorten an ARV after SEMS deployment.
652 GASTRIC NECROSIS: A COMPLICATION OF GASTRIC BANDING Gerald Fruchter, M.D.*, Vlado Simko, M.D., Hatem Shoukeir, M.D., Hueldine Webb, M.D., Ayse Aytaman, M.D. VA NY Harbor HCS, Brooklyn, NY. Background: Morbid obesity is a growing health problem in the United States. Patients, who fail conservative measures at weight loss, are potential candidates for bariatric surgery. Current weight reduction surgery techniques include gastric restriction procedures, gastric bypass, and biliopancreatic bypass. We report a rare, potentially lethal, complication of gastric banding: gastric necrosis necessitating emergent laparotomy and gastrectomy.
AJG – Vol. 98, No. 9, Suppl., 2003
Case Report: A 55 year-old male with history of morbid obesity presented with 5 days of epigastric pain, progressive dysphagia, and vomiting. He had undergone a laparoscopic gastric banding 7 years prior with subsequent loss of 150lbs. Upon presentation, the patient was in no distress, weight 187lbs with stable vital signs. Abdominal exam revealed a soft, nondistended abdomen with mild epigastric tenderness, no guarding or rebound with a LUQ subcutaneous reservoir. The WBC was 9.2. CXR and abdominal films were unremarkable. Esophagogram showed marked constriction at the level of the gastric band encircling the fundus with significant hang-up of barium. On the second day of hospital stay, WBC rose to 29.7; exam was unchanged. An abdominal CT scan was unrevealing except for a left lung base infiltrate. Antibiotics were initiated. The following day, patient’s WBC rose to 35.2 with an unchanged exam. Upper endoscopy revealed a distended proximal gastric pouch filled with coffee ground liquid and a large area of confluent ischemia covered by eschar as well as multiple small islands of ischemia. At surgery, there were multiple areas of necrosis in the serosal surface of the dilated fundus proximal to the strangulating ring as well as evidence of peritonitis. The stomach contained over 3 liters of sloughed gastric lining. A near total gastrectomy with roux-en-y gastrojejunostomy was performed. Pathological exam revealed transmural hemorrhagic necrosis of the fundus with marked thinning and impending perforation. The patient had an uneventful post-op course. Discussion: Bariatric surgery is effective in treating morbid obesity. For gastric banding, revision is occasionally needed to address gastric slippage, stenosis, as well as stomal obstruction. In our case, gastric banding induced strangulation with resultant full-thickness gastric necrosis and peritonitis. Clinicians involved in management of patients who undergo bariatric surgery need to be aware of the potentially serious consequences inherent in this form of surgery.
653 SUPRAGLOTTIC LARYNGEAL STENOSIS-A RARE EXTRAESOPHAGEAL MANIFESTATION OF GERD Sailaja M. Cheruku, M.D., John O’Brien, M.D.*, Carl Malone, M.D. Southern Illinois University School of Medicine, Springfield, IL. A 60 year-old caucasian female admitted to hospital for progressive, severe shortness of breath, over the past 2–3 weeks. She was sleeping upright in a chair secondary to orthopnea. She has no history of recent fever or acute illness. Past medical history included chronic heart burn, hypertension and obesity. She denied tobacco, alcohol and illicit drug use. She took over the counter antacids for heart burn. On exam, she had audible inspiratory stridor and room air oxygen saturation was 80%. An urgent transnasal fiberoptic laryngoscopy showed inability to visualize true vocal cords and a large 2⫻3 cm mass along the right aryepiglottic fold extending back to posterior commissure completely obstructing the view of her glottis. The impression was supraglottic mass obstructing the air way. She underwent emergency tracheostomy and direct laryngoscopic biopsy of the mass. Histology showed severe inflammation with granulation tissue and no evidence of malignancy. Laboratory evaluation of anti nuclear antibody, anti neutrophil cytoplasmic antibody and angiotensin converting enzyme levels were normal. Her sedimentation rate was 22. A CT Scan of neck showed normal appearance of true vocal cords and severe supraglottic stenosis. In consideration of acid reflux induced ulceration, an upper endoscopy was performed, which demonstrated a hiatal hernia, normal esophagus, stomach and duodenum. She was given Pantoprazole twice daily and discharged home to follow up as out patient, as her post operative course was uneventful. Ten weeks after treatment with pantoprazole, she was evaluated with videostroboscopy and fiberoptic nasopharyngolaryngoscopy, which demonstrated significant decrease in supraglottic swelling and inflammation. She denied any episodes of acid reflux. Despite discussions regarding surgery for acid reflux, the patient declined surgery. She is currently taking once a day pantoprazole. The Plan is to do supraglottic laryngectomy and removal of tracheostomy tube. Common otolaryngologic manifestations of GERD include cough, sore throat, hoarseness, laryngitis, chronic sinusitis, vocal cord nodules, globus, subglottic stenosis and rarely
AJG – September, Suppl., 2003
laryngeal cancer. So this is an extremely rare case of “supraglottic laryngeal stenosis” from GERD. Majority of patiens lack GERD symptoms and have low prevelance of esophagitis. An emperic trial of twice daily PPI for a minimum of 3 months is the preferred diagnostic and treatment approach. 654 ENDOSCOPIC THERAPY OF EARLY GASTRIC CANCER Robert P. Yatto, M.D.*, Elizabeth Petty, M.D., James Barnwell, M.D. Cumberland Medical Center, Crossville, TN. A 67 year-old white female was referred for evaluation of anemia and occult GI bleeding. An EGD revealed a polypoid pre-pyloric lesion that was removed by snare. Histopathology revealed well differentiated adenocarcinoma that did not arise from an underlying adenoma. A repeat endoscopy was done to remove tissue at the base by endoscopic mucosal resection (EMR). Three injections of 7–10 cc of saline were used to lift the base from the submucosa. No residual cancer was seen in the mucosa or submucosa of the base tissue removed during EMR.. Subsequent endoscopic ultrasound was unremarkable for gastric wall or regional lymph node abnormalties. The Japanese classification of this lesion is Type I-protruded. Mucosal cancer is seldom associated with lymph node metastases, whereas submucosal cancer has lymph node metastatic rates of 10 – 40%. It is the possibilty of lymph node invasion that is the most serious limitation of EMR. Surgical series of resected early gastric cancer demonstrate that lymph node involvement can be correlated to the diameter and depth of the superficial gastric tumor, in addition to histology. It can be stated that EMR is indicated in the resection of superficial early gastric cancer when the cancer is well differentiated, limited to the mucosa, and less than 20 mm in diameter. While such lesions are often found in Japan, only four have been reported in the US. This represents the first such lesion treated in a community hospital. This aggressive form of endoscopic therapy is safe and effective and avoids surgery and it’s associated morbidity and mortality. It is attractive because of a demand for minimally invasive procedures in the US, and because the rare association of these lesions with lymph node metastases and long term studies showing EMR patient outcomes similar to surgery.
OUTCOMES RESEARCH 655 THE IMPACT OF TEACHING SURGICAL RESIDENTS ON COLONOSCOPIC PROCEDURE TIME AND SEDATION USED Nirmal S. Mann, M.D.*, Joseph W. Leung, M.D. U.C. Davis and VAMC Martinez, Martinez, CA. Introduction: From July 1, 1999 to November 15, 2002, one of the faculty GI Endoscopists (NSM) was involved in the performance of 1062 colonoscopic procedures. He performed them either alone (Group I) or while teaching a general surgery resident (Group II). Aims: To compare the procedure time (MPT) and the amount of sedation (S) used between Groups I & II. Methods: Records of patients on these 1062 cases were evaluated. The records were evaluated for age, gender, procedure time, amount of Midzolam and Fentanyl used, quality of preparation, diagnoses after endoscopy. The frequency of faculty intervention (FI) to complete the procedure was noted. The results are expressed as mean ⫾ standard error of the mean. The means were compared by t-test and the percentages were compared using Chi square test. Results: There were 829 patients in Group I and 233 patients in Group II. There were 800 (96.5%) men and 29 women (3.5%) in Group I and 225 men (96.5%) and 8 (3.5%) women in Group II. The mean age in Group I was 60.3 ⫾ 4.4 years (range 30-92) and it was 62.7 ⫾ 5.8 years (range 30-91) in Group II. The preparation was good or fair in 755 (91%) and poor in 64 (9%) patients in Group I; it was good or fair in 207 (89%) and poor in 26 (11%) patients in Group II. The diagnoses in Group I were: Normal
Abstracts
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259 (31.2%), Diverticulosis alone 262 (31.6%); Diverticulosis plus polyps and/or cancer 133 (16.0%); polyps or cancer alone 106 (12.7%) and others 69 (8.3%). The figures for Group II are 66 (28.3%), 73 (31.3%); 37 (15.8%) 44 (18.8%) and 13 (5.5%). The MPT for Group I was 17.4 ⫾ 3.7 minutes (range 5– 60). The MPT for Group II was 27.8 ⫾ 5.6 minutes (range 6 –72). The mean amount of Midzolam used in Group I was 1.9 ⫾ 0.2 mgms (range 0-6); for Group II it was 2.5 ⫾ 0.3 mgms (range 0 – 6). The mean amount of Fentanyl for Group I was 81.3 ⫾ 6.4 micrograms range (0 –250); for Group II it was 106.4 ⫾ 8.2 micrograms (range 0 –250). FI occurred in 62 cases (26.6%) in Group II. The MPT and the S used was significantly increased in Group II patients (p⬍0.05); in other respects e.g. age, gender distribution, quality of colonic preparation and post procedure diagnoses the two group were similar (p⬎0.05). Conclusions: The colonoscopic procedure time is significantly increased when the faculty teaches colonoscopy to surgical residents and seems to increase the need for sedation, which may be a reflection of increased procedure time.
656 A CLINICAL SURVEY COMPARING THE EFFECTIVENESS OF ESOMEPRAZOLE AND PANTOPRAZOLE TO TRADITIONAL PPIS (OMEPRAZOLE AND LANSOPRAZOLE) IN RELIEVING SEVERE HEARTBURN Mohammad Farivar, M.D.*, Alexander S. Farivar, M.D., Robert S. Farivar, M.D. Harvard Medical School, Boston, MA; University of Washington Medical Center, Seattle, WA and Brigham & Women’s Hospital. Harvard Medical School, Boston, MA. Purpose: It is generally believed that iso-potent doses of proton pump inhibitors (PPIs) are equally effective in relieving heartburn. This survey was done to test the efficacy of esomeprazole (Nexium) and pantoprazole ( Protonix) to the traditional PPIs, lansoprazole (Prevacid) and omeprazole (Prilosec), in providing heartburn relief. Methods: Over a three-month period 27 consecutive patients (16 females and 11 males, aged 25– 80 years) with a history of frequent daily and nightly heartburn were included in this study. Index endoscopy had revealed erosive esophagitis in 13 patients prior to initiation of PPI treatment. All patients were asked to discontinue their regimen of lansoprazole (30 mg) or omeprazole (20 – 40 mg), and to take esomeprazole (40 mg), followed by pantoprazole (40 mg) (or vice versa) for one month. Patients were given a survey asking them to compare the effectiveness of their established regimen of omeprazole or lansoprazole to equivalent doses of pantoprazole and esomeprazole. All surveys were completed and returned. Daily Heartburn was graded from 1 (not often) to 5 (very often) during both day and night. Patient satisfaction with medication was graded from 1 (not satisfied) to 5 (very satisfied). Results: Average heartburn score prior to PPI treatment was 4.61 during the day and 4.06 at night. All patients had been on varying doses of omeprazole and lansoprazole for years with significant (p⬍0.01) heartburn score improvement (1.37 during the day and 1.55 at night). On esomeprazole, heartburn score improved to 1.29 during the day and 1.33 at night. On pantoprazole, heartburn score increased significantly (p⬍0.01) to 3.48 during the day and 3.10 at night. Heartburn score changes with all PPIs represent statistically significant improvement comparing to no PPI treatment. Similarly, satisfaction scores were lowest at 2.06 with pantoprazole and highest at 4.44 with esomeprazole. Conclusions: When comparing pantoprazole and esomeprazole to traditional PPIs, esomeprazole subjectively provided slightly better heartburn relief, but was not statistically significant. Pantoprazole was significantly worse in providing heartburn relief compared to the other PPIs. Further surveys will need to be performed as our experience with these newer PPIs increases.