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Tu1178 Is the PPI Necessary for an Ulcer After Esophagus ESD ?: Comparison Using Propensity Score Matching
Abstracts
Tu1177 Outcomes of Endoscopic Submucosal Dissection (ESD) for Patients With Barrett’s Esophagus Nodules or Early Esophageal Adenocarcinoma (EAC), a United States Experience Mohamed O. Othman*, Nedaa Husainat, Abdalaziz Tabash, Sadhna Dhingra Baylor College of Medicine, Houston, TX
Initial submucosal incision
Introduction: ESD has emerged as a superior technique for resection of early cancerous lesion of the gastrointestinal tract. ESD allows en block resection and better assessment of the histological margins. However, ESD is technically difficult and could be associated with a higher risk of complications. ESD is commonly performed for early gastric cancer in the East. In the U.S., Barrett’s esophagus and its complications could be practical applications for ESD. In this abstract, we present the outcomes of ESD for the management of Barrett’s esophageal nodule and early EAC in a major tertiary referral center in the U.S. Methods: All patients undergoing ESD for resection of Barrett’s esophageal nodules (larger than 2 cm) or early EAC were included. The study period was from August 2015 to October 2016. Demographic information, procedure details and follow-up information were obtained. Means and standard deviation were used for continuous data. Frequency statistics was used to describe categorical data. R0 resection was defined as deep and peripheral margin free of dysplasia. All procedures were performed with Dual knife and IT Nano knife. One endoscopist performed all procedures. The endoscopist was trained in the U.S., mainly though the ASGE Asian Master ESD Course in 2013, 2014. Results: 14 patients (10 males/4 Females) met the inclusion criteria. Mean age was 70 + 2 yrs. Mean size of the resected lesion was 3.5 + 0.3 cm. En Bloc resection was achieved in all patients. R0 resection was achieved in 12 (85%) patients. Curative resection was achieved in 11 patients (78.5%). Pathology showed invasive EAC into muscularis mucosa in 4 patients and into submucosa in 3 patients, Barrett’s with HGD dysplasia in 3 patients and Barrett’s nodule without dysplasia in 4 patients. A small perforation was noted in one patient during the procedure and it was managed endoscopically. Esophageal Stricture was seen in 1 patient 3 months after the procedure and it was treated by one session of endoscopic balloon dilation. Follow-up data was available for 9 patients. No recurrence of adenocarcinoma or dysplasia was seen in any patients (mean follow-up period is 133 + 33 days). Conclusion: ESD is an attractive therapeutic intervention for early esophageal adenocarcinoma and large Barrett’s nodule. The ability to obtain dysplastic free peripheral and deep margins in esophageal lesions larger than 2 cm or superficial submucosal lesions could be the rational for expanding ESD practice in the United States. Post ESD resection bed
Tu1178 Is the PPI Necessary for an Ulcer After Esophagus ESD ?: Comparison Using Propensity Score Matching Yoshiaki Takahashi*, Toshihisa Takeuchi, Shinpei Kawaguchi, Yosuke Inoue, Haruhiko Ozaki, Shoko Edogawa, Kazuhiro Ota, Yuichi Kojima, Satoshi Harada Osaka Medical College, Takatsuki, Japan Background: The efficacy of endoscopic resection techniques, including EMR and ESD, for superficial esophageal cancer has previously been shown. Many studies have reported the usefulness of PPI in gastric (but not esophageal) ulcer healing after endoscopic treatment and in the prevention of postoperative bleeding. In this retrospective study, we aimed to investigate the effect of PPIs on the healing of ulcers after the endoscopic resection of superficial esophageal lesions. Methods: A total of 199 patients underwent ESD for superficial esophageal cancer and dysplasia
AB570 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
www.giejournal.org
Abstracts
in our hospital between April 2005 and August 2015. Of these patients, 88 who had undergone EGD 1 month after ESD were studied. Forty-seven patients in the oral-PPI group and 41 patients in the non-oral-PPI group were pseudo-randomized using the propensity score. The risk of ulcer persistence was assessed using the ulcer healing rate at 1 month after ESD as the main item. Age at ESD, sex, BMI, protective factors, steroids, diabetes, hypertension, hyperlipidemia, anticoagulants, resected specimen area, esophageal hiatal hernia, atrophic gastritis, Barrett’s esophagus, reflux esophagitis, and distance from the incisor teeth to the upper end of the lesion (FIT) were used as covariates influencing ulcer healing. and adjusted between the oral PPI and non-oralPPI groups, who were pseudo-randomized. Results: Ulcer scarring rate after four weeks of oral PPI group 47 cases was 74% (35/47). PPI 85% in the non-oral group 41 patients (35/41). After adjusted by propensity score, Age at ESD (mean SD): p Z 0.596, sex (male / female): p Z 0.574 BMI: p Z 0.569 protective factor (Yes / No): p Z 0.524 steroids (Yes): p Z 0.62 diabetes (Yes / No): p Z 0.572 hypertension (Yes / No): p Z 0.063 hyperlipidemia (Yes / No): p Z 0.587, anticoagulants : p Z 0.42, resected specimen area (mm2): p Z 0.255, esophageal hiatal hernia (Yes / No): p Z 0.592 Barrett’s esophagus (Yes / No): p Z 0.237 reflux esophagitis (Yes / No): p Z 0.316 FIT (cm): p Z 0.185 A background factor did not have the difference between groups and performed pseudo randomization. The odds ratio for the risk of ulcer persisting at 1 month after ESD was 2.42 (95% CIZ0.73-7.97)p＝0.15, showing no advantage of oral PPI administration for ulcer healing after ESD for early esophageal cancer. Conclusion: We could not confirm the usefulness of oral PPI administration for ulcer healing after ESD for early esophageal cancer. This suggests that oral PPI administration is not necessary for post-ESD esophageal ulcers.
Tu1179 Lymphocytic Esophagitis and Eosinophilic Esophagitis: A Comparison of Demographics, Clinical Symptoms and Endoscopic Findings Meera Avila*1, Bijun S. Kannadath1, Manju Ambelil2, Nathaniel Avila1, Patrick Yu1, Nirav Thosani1, Atilla Ertan1, Andrew Dupont1, Sushovan Guha1, Mamoun Younes2, Erik F. Rahimi1 1 Gastroenterology, Hepatology, and Nutrition, University of Texas Health Science Center at Houston, Houston, TX; 2Pathology, University of Texas Health Science Center at Houston, Houston, TX Introduction: Eosinophilic esophagitis (EoE) and lymphocytic esophagitis (LyE) are characterized by numerous intraepithelial eosinophils or lymphocytes respectively, along with esophageal symptoms. EoE has been well studied over the past 20 years, however LyE is a relatively new entity first described 10 years ago. Here we aim to evaluate demographic data, clinical, and endoscopic findings in patients affected by these two clinical entities. Methods: A retrospective cohort study was performed on patients who were found to have lymphocytosis on esophageal biopsies or patients who underwent biopsies for suspected EoE between January 2013 and December 2014. A total of 75 patients met criteria for LyE and 46 patients met criteria for EoE. A minimum cutoff of 15 eosinophils per high power field (hpf) for EoE, and 20 lymphocytes / hpf for LyE (as used by Pasricha et al, Dig Dis Sci, 2016) was used to define the conditions, along with other appropriate histologic characteristics. Demographic data, clinical symptoms, and endoscopic findings were compared between the two groups using the Fisher’s exact and Chi-square tests. Results: The mean age of patients in the EoE group was 44 years old, whereas 57 was the mean age of LyE patients. Males were more commonly affected by EoE, comprising 65.2% of the total group. Females were more commonly affected by LyE, comprising 69.3% of the total group. BMI was similar in patients in both groups. Dysphagia (pZ 0.018) and food impaction (pZ0.017) were more common in the EoE group. Hoarseness was more prevalent in the LyE group (pZ0.043). Other symptoms, such as reflux, abdominal pain, vomiting, and bloating were similar in the two groups. There was no significant difference in the prevalence of co-morbid conditions, such as asthma, allergic rhinitis, IBS, IBD, or Barrett’s esophagus. Normal EGD findings were seen in more patients with LyE compared to patients with EoE (pZ0.015). A ringed appearance of the esophagus on EGD was seen more commonly in patients with EoE (pZ0.001). Other endoscopic features were seen in similar proportions in the two groups, including esophagitis, strictures, Schatzki rings, Barrett’s mucosa. Discussion: EoE and LyE are two pathologically distinct clinical entities. EoE seems to affect men and a younger age group, whereas LyE has a female predominance and affects an older age group. There is considerable overlap between the two groups in terms of clinical symptoms and comorbid conditions. However, dysphagia and food impaction were more commonly encountered in the EoE group, whereas hoarseness was more prevalent in the LyE group. Endoscopically, EoE patients more often had a ringed esophagus or felinization, while LyE patients more commonly had a normal-appearing esophagus.
www.giejournal.org
Symptoms - EoE and LyE groups Abdominal pain Bloating Chest pain Constipation Diarrhea Dysgeusia Dysphagia Early satiety Food impaction Hoarseness Nausea Reflux Vomiting Weight gain Weight loss
EoE group (46 patients) 21 5 1 6 5 1 31 2 14 0 9 33 9 0 1
LyE group (75 patients) 36 10 5 6 14 1 34 7 9 7 14 58 7 1 2
p-value 0.802* 0.782 0.406 0.369 0.310 1.000 0.018* 0.480 0.017 0.043 1.000 0.489* 0.783 1.000 1.000
* P-values derived from Chi-squared test, others with Fisher’s Exact test Endoscopic findings
Barrett Dilated esophagus Esophagitis Felinization (ringed esophagus) Furrowing Irregular mucosa Irregular z-line Normal mucosa Schatzki ring Stricture
EoE group (46 patients) 7 0 8 14
LyE group (75 patients) 17 1 13 5
pvalue 0.357 1.000 1.000 0.001
6 4 5 8 3 6
4 4 12 29 7 2
0.177 0.477 0.592 0.015 0.740 0.052
P-values derived from Fischer’s Exact test
Tu1180 Implementation of Endoscopic Submucosal Dissection of Upper Gastrointestinal Lesions in the United States: A Single-Center Experience Alvaro Martínez- Alcalá*4, Paul T. Kroner5, Seiichiro Abe2,3, Yutaka Saito2, Klaus E. Monkemuller3,1 1 Gastroenterology, Helios Frankenwald Klinik, Kronach, Germany; 2 Endoscopy, National Cancer Center, Tokyo, Japan; 3Endoscopy, University of Alabama, Birmingham, AL; 4Gastroenterology, Centro de Innovaciones Digestivas Martinez-Alcala, Sevilla, Spain; 5Internal Medicine/Gastroenterology, Mount Sinai-Roosevelt’s Hospital, New York, NY Background: Endoscopic submucosal dissection has been adopted in Asia and Europe. However, there is lack of data on its implementation and usefulness in the United States. Aims: To evaluate the development of ESD in the United States by analyzing the steps of implementation, technique and outcomes. Methods: Retrospective, single-center cohort study reviewing all cases in which upper GI ESD technique was used. All procedures were performed by one therapeutic endoscopist. The following information was collected: experience of endoscopist, type of training, process of implementation, location of the lesion, indication, procedure time, and instruments used, submucosal injection solutions, complications and follow-up. Results: The endoscopist trained using a stepwise approach. First, three courses focusing on ESD were visited. Second, the endoscopist trained on ex-vivo biologic model performing 15 cases, five under expert supervision and 10 on his own. Third, a one week mini-fellowship at a tertiary ESD center (National Cancer Center, Tokyo) was done. Fourth, an expert from NCC visited the endoscopist for 30-days and observed all cases of advanced endoscopic resection. A total of 50 ESD procedures were performed during a 21/2 year period. The lesions treated by ESD were located in the esophagus (n Z 22: Barrett neoplasia n Z 9, early squamous cell cancer n Z 6, other n Z 7), stomach (n Z 22, early stomach cancer n Z 5, adenoma n Z 10, submucosal tumors n Z 3, other n Z 4), duodenum (n Z 5, adenoma n Z 4, carcinoid n Z 2). The mean lesion size was 40 mm (SD +/- 24.4mm, range 8 – 65 mm). En bloc resection was achieved in 76.0%, with complete R0 resection in 88%. The median ESD procedure time was 75 minutes (range 25 – 310). The most frequent instruments used included the IT knife (90%). Complications included bleeding in 4 cases (8%), two requiring blood transfusion,
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB571
Tu1177 Outcomes of Endoscopic Submucosal Dissection (ESD) for Patients With Barrett’s Esophagus Nodules or Early Esophageal Adenocarcinoma (EAC), a United States Experience Mohamed O. Othman*, Nedaa Husainat, Abdalaziz Tabash, Sadhna Dhingra Baylor College of Medicine, Houston, TX
Initial submucosal incision
Introduction: ESD has emerged as a superior technique for resection of early cancerous lesion of the gastrointestinal tract. ESD allows en block resection and better assessment of the histological margins. However, ESD is technically difficult and could be associated with a higher risk of complications. ESD is commonly performed for early gastric cancer in the East. In the U.S., Barrett’s esophagus and its complications could be practical applications for ESD. In this abstract, we present the outcomes of ESD for the management of Barrett’s esophageal nodule and early EAC in a major tertiary referral center in the U.S. Methods: All patients undergoing ESD for resection of Barrett’s esophageal nodules (larger than 2 cm) or early EAC were included. The study period was from August 2015 to October 2016. Demographic information, procedure details and follow-up information were obtained. Means and standard deviation were used for continuous data. Frequency statistics was used to describe categorical data. R0 resection was defined as deep and peripheral margin free of dysplasia. All procedures were performed with Dual knife and IT Nano knife. One endoscopist performed all procedures. The endoscopist was trained in the U.S., mainly though the ASGE Asian Master ESD Course in 2013, 2014. Results: 14 patients (10 males/4 Females) met the inclusion criteria. Mean age was 70 + 2 yrs. Mean size of the resected lesion was 3.5 + 0.3 cm. En Bloc resection was achieved in all patients. R0 resection was achieved in 12 (85%) patients. Curative resection was achieved in 11 patients (78.5%). Pathology showed invasive EAC into muscularis mucosa in 4 patients and into submucosa in 3 patients, Barrett’s with HGD dysplasia in 3 patients and Barrett’s nodule without dysplasia in 4 patients. A small perforation was noted in one patient during the procedure and it was managed endoscopically. Esophageal Stricture was seen in 1 patient 3 months after the procedure and it was treated by one session of endoscopic balloon dilation. Follow-up data was available for 9 patients. No recurrence of adenocarcinoma or dysplasia was seen in any patients (mean follow-up period is 133 + 33 days). Conclusion: ESD is an attractive therapeutic intervention for early esophageal adenocarcinoma and large Barrett’s nodule. The ability to obtain dysplastic free peripheral and deep margins in esophageal lesions larger than 2 cm or superficial submucosal lesions could be the rational for expanding ESD practice in the United States. Post ESD resection bed
Tu1178 Is the PPI Necessary for an Ulcer After Esophagus ESD ?: Comparison Using Propensity Score Matching Yoshiaki Takahashi*, Toshihisa Takeuchi, Shinpei Kawaguchi, Yosuke Inoue, Haruhiko Ozaki, Shoko Edogawa, Kazuhiro Ota, Yuichi Kojima, Satoshi Harada Osaka Medical College, Takatsuki, Japan Background: The efficacy of endoscopic resection techniques, including EMR and ESD, for superficial esophageal cancer has previously been shown. Many studies have reported the usefulness of PPI in gastric (but not esophageal) ulcer healing after endoscopic treatment and in the prevention of postoperative bleeding. In this retrospective study, we aimed to investigate the effect of PPIs on the healing of ulcers after the endoscopic resection of superficial esophageal lesions. Methods: A total of 199 patients underwent ESD for superficial esophageal cancer and dysplasia
AB570 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
www.giejournal.org
Abstracts
in our hospital between April 2005 and August 2015. Of these patients, 88 who had undergone EGD 1 month after ESD were studied. Forty-seven patients in the oral-PPI group and 41 patients in the non-oral-PPI group were pseudo-randomized using the propensity score. The risk of ulcer persistence was assessed using the ulcer healing rate at 1 month after ESD as the main item. Age at ESD, sex, BMI, protective factors, steroids, diabetes, hypertension, hyperlipidemia, anticoagulants, resected specimen area, esophageal hiatal hernia, atrophic gastritis, Barrett’s esophagus, reflux esophagitis, and distance from the incisor teeth to the upper end of the lesion (FIT) were used as covariates influencing ulcer healing. and adjusted between the oral PPI and non-oralPPI groups, who were pseudo-randomized. Results: Ulcer scarring rate after four weeks of oral PPI group 47 cases was 74% (35/47). PPI 85% in the non-oral group 41 patients (35/41). After adjusted by propensity score, Age at ESD (mean SD): p Z 0.596, sex (male / female): p Z 0.574 BMI: p Z 0.569 protective factor (Yes / No): p Z 0.524 steroids (Yes): p Z 0.62 diabetes (Yes / No): p Z 0.572 hypertension (Yes / No): p Z 0.063 hyperlipidemia (Yes / No): p Z 0.587, anticoagulants : p Z 0.42, resected specimen area (mm2): p Z 0.255, esophageal hiatal hernia (Yes / No): p Z 0.592 Barrett’s esophagus (Yes / No): p Z 0.237 reflux esophagitis (Yes / No): p Z 0.316 FIT (cm): p Z 0.185 A background factor did not have the difference between groups and performed pseudo randomization. The odds ratio for the risk of ulcer persisting at 1 month after ESD was 2.42 (95% CIZ0.73-7.97)p＝0.15, showing no advantage of oral PPI administration for ulcer healing after ESD for early esophageal cancer. Conclusion: We could not confirm the usefulness of oral PPI administration for ulcer healing after ESD for early esophageal cancer. This suggests that oral PPI administration is not necessary for post-ESD esophageal ulcers.
Tu1179 Lymphocytic Esophagitis and Eosinophilic Esophagitis: A Comparison of Demographics, Clinical Symptoms and Endoscopic Findings Meera Avila*1, Bijun S. Kannadath1, Manju Ambelil2, Nathaniel Avila1, Patrick Yu1, Nirav Thosani1, Atilla Ertan1, Andrew Dupont1, Sushovan Guha1, Mamoun Younes2, Erik F. Rahimi1 1 Gastroenterology, Hepatology, and Nutrition, University of Texas Health Science Center at Houston, Houston, TX; 2Pathology, University of Texas Health Science Center at Houston, Houston, TX Introduction: Eosinophilic esophagitis (EoE) and lymphocytic esophagitis (LyE) are characterized by numerous intraepithelial eosinophils or lymphocytes respectively, along with esophageal symptoms. EoE has been well studied over the past 20 years, however LyE is a relatively new entity first described 10 years ago. Here we aim to evaluate demographic data, clinical, and endoscopic findings in patients affected by these two clinical entities. Methods: A retrospective cohort study was performed on patients who were found to have lymphocytosis on esophageal biopsies or patients who underwent biopsies for suspected EoE between January 2013 and December 2014. A total of 75 patients met criteria for LyE and 46 patients met criteria for EoE. A minimum cutoff of 15 eosinophils per high power field (hpf) for EoE, and 20 lymphocytes / hpf for LyE (as used by Pasricha et al, Dig Dis Sci, 2016) was used to define the conditions, along with other appropriate histologic characteristics. Demographic data, clinical symptoms, and endoscopic findings were compared between the two groups using the Fisher’s exact and Chi-square tests. Results: The mean age of patients in the EoE group was 44 years old, whereas 57 was the mean age of LyE patients. Males were more commonly affected by EoE, comprising 65.2% of the total group. Females were more commonly affected by LyE, comprising 69.3% of the total group. BMI was similar in patients in both groups. Dysphagia (pZ 0.018) and food impaction (pZ0.017) were more common in the EoE group. Hoarseness was more prevalent in the LyE group (pZ0.043). Other symptoms, such as reflux, abdominal pain, vomiting, and bloating were similar in the two groups. There was no significant difference in the prevalence of co-morbid conditions, such as asthma, allergic rhinitis, IBS, IBD, or Barrett’s esophagus. Normal EGD findings were seen in more patients with LyE compared to patients with EoE (pZ0.015). A ringed appearance of the esophagus on EGD was seen more commonly in patients with EoE (pZ0.001). Other endoscopic features were seen in similar proportions in the two groups, including esophagitis, strictures, Schatzki rings, Barrett’s mucosa. Discussion: EoE and LyE are two pathologically distinct clinical entities. EoE seems to affect men and a younger age group, whereas LyE has a female predominance and affects an older age group. There is considerable overlap between the two groups in terms of clinical symptoms and comorbid conditions. However, dysphagia and food impaction were more commonly encountered in the EoE group, whereas hoarseness was more prevalent in the LyE group. Endoscopically, EoE patients more often had a ringed esophagus or felinization, while LyE patients more commonly had a normal-appearing esophagus.
www.giejournal.org
Symptoms - EoE and LyE groups Abdominal pain Bloating Chest pain Constipation Diarrhea Dysgeusia Dysphagia Early satiety Food impaction Hoarseness Nausea Reflux Vomiting Weight gain Weight loss
EoE group (46 patients) 21 5 1 6 5 1 31 2 14 0 9 33 9 0 1
LyE group (75 patients) 36 10 5 6 14 1 34 7 9 7 14 58 7 1 2
p-value 0.802* 0.782 0.406 0.369 0.310 1.000 0.018* 0.480 0.017 0.043 1.000 0.489* 0.783 1.000 1.000
* P-values derived from Chi-squared test, others with Fisher’s Exact test Endoscopic findings
Barrett Dilated esophagus Esophagitis Felinization (ringed esophagus) Furrowing Irregular mucosa Irregular z-line Normal mucosa Schatzki ring Stricture
EoE group (46 patients) 7 0 8 14
LyE group (75 patients) 17 1 13 5
pvalue 0.357 1.000 1.000 0.001
6 4 5 8 3 6
4 4 12 29 7 2
0.177 0.477 0.592 0.015 0.740 0.052
P-values derived from Fischer’s Exact test
Tu1180 Implementation of Endoscopic Submucosal Dissection of Upper Gastrointestinal Lesions in the United States: A Single-Center Experience Alvaro Martínez- Alcalá*4, Paul T. Kroner5, Seiichiro Abe2,3, Yutaka Saito2, Klaus E. Monkemuller3,1 1 Gastroenterology, Helios Frankenwald Klinik, Kronach, Germany; 2 Endoscopy, National Cancer Center, Tokyo, Japan; 3Endoscopy, University of Alabama, Birmingham, AL; 4Gastroenterology, Centro de Innovaciones Digestivas Martinez-Alcala, Sevilla, Spain; 5Internal Medicine/Gastroenterology, Mount Sinai-Roosevelt’s Hospital, New York, NY Background: Endoscopic submucosal dissection has been adopted in Asia and Europe. However, there is lack of data on its implementation and usefulness in the United States. Aims: To evaluate the development of ESD in the United States by analyzing the steps of implementation, technique and outcomes. Methods: Retrospective, single-center cohort study reviewing all cases in which upper GI ESD technique was used. All procedures were performed by one therapeutic endoscopist. The following information was collected: experience of endoscopist, type of training, process of implementation, location of the lesion, indication, procedure time, and instruments used, submucosal injection solutions, complications and follow-up. Results: The endoscopist trained using a stepwise approach. First, three courses focusing on ESD were visited. Second, the endoscopist trained on ex-vivo biologic model performing 15 cases, five under expert supervision and 10 on his own. Third, a one week mini-fellowship at a tertiary ESD center (National Cancer Center, Tokyo) was done. Fourth, an expert from NCC visited the endoscopist for 30-days and observed all cases of advanced endoscopic resection. A total of 50 ESD procedures were performed during a 21/2 year period. The lesions treated by ESD were located in the esophagus (n Z 22: Barrett neoplasia n Z 9, early squamous cell cancer n Z 6, other n Z 7), stomach (n Z 22, early stomach cancer n Z 5, adenoma n Z 10, submucosal tumors n Z 3, other n Z 4), duodenum (n Z 5, adenoma n Z 4, carcinoid n Z 2). The mean lesion size was 40 mm (SD +/- 24.4mm, range 8 – 65 mm). En bloc resection was achieved in 76.0%, with complete R0 resection in 88%. The median ESD procedure time was 75 minutes (range 25 – 310). The most frequent instruments used included the IT knife (90%). Complications included bleeding in 4 cases (8%), two requiring blood transfusion,
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB571