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Tu1186 Post-Procedural Pain Associated With Endoscopic Ablation Therapy of Barrett's Esophagus: Post-Hoc Comparison Between Radiofrequency Ablation and Cryoballoon Ablation
Abstracts
Tu1185 Flat Dysplasia Is Preferentially Localized to the Proximal Segment of Barrett’s Esophagus: A Single Center Study of 264 Patients Tanmayee Benjamin*1, Deepa T. Patil2, Ilyssa Gordon2, John R. Goldblum2, Madhusudhan R. Sanaka1, Rocio Lopez3, John J. Vargo1, Prashanthi N. Thota1 1 Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH; 2 Pathology, Cleveland Clinic Foundation, Cleveland, OH; 3Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH Background: Although dysplasia continues to be the best available biomarker of Barrett’s esophagus (BE) neoplastic progression, it is frequently flat and patchy in distribution, supporting the rationale for surveillance with random four quadrant biopsies taken at each centimeter of BE. The goal of this study was to systematically assess the spatial distribution of flat dysplasia in BE segment and compare the findings with a cohort of patients with endoscopically visible lesions (VL). Methods: BE patients referred for endoscopic eradication therapy (EET) between 2011 and 2015 were categorized into those with flat dysplasia (study group) and those who had VL prior to or during EET (comparison group). Demographic data, detailed endoscopic findings including length of the BE segment, hiatal hernia size, endoscopic level of biopsy and histological findings were reviewed. The location of dysplasia was standardized based on the length of BE segment. Top of the gastric folds was assigned a value of 0, maximal extent of squamocolumnar junction, a value of 1 and midpoint of BE segment was assigned 0.5. In cases of multifocal dysplasia, the lowest level is used for calculation. Results: Of the total 264 patients, 34 patients formed the study group (median age: 65 years; M:F : 5:1) and 230 belonged to the comparison group (Table 1). The study group had shorter BE segments. Majority of the patients in study group showed low grade dysplasia (LGD), while those in the comparison group showed high grade dysplasia (HGD) or cancer (Table 1; p<0.001). There were no significant demographic differences between flat dysplasia group and VL group. In half of the study group, the worst grade of dysplasia was found in the proximal third of BE segment. In the comparison group, the worst dysplasia was located in the proximal two-fifths of the BE segment (location in flat dysplasia group 0.71, VL group 0.6). While multifocal LGD was seen in both the groups, multifocal HGD was only observed in the comparison group. Conclusions: Flat dysplasia is preferentially located in the proximal segment of BE and is predominantly low-grade in morphology. This finding suggests that in patients referred for EET, aggressive sampling of the proximal BE segment may reveal additional foci of dysplasia and influence endoscopic management.
Introduction: Radiofrequency ablation (RFA) has been shown to be safe and effective for eradication of Barrett’s Esophagus (BE), but is associated with significant pain in a proportion of patients. As an alternative, CryoBalloon ablation (CBA) has recently been developed. In contrast to heat-based ablation technology, CBA preserves the extracellular matrix which might be associated with less pain while maintaining sufficient depth of ablation. Aim: To compare post-procedural pain between focal RFA and CBA Methods: This post-hoc analysis was performed on pain scores derived from two separate prospective studies assessing the safety and efficacy of RFA and CBA respectively, for the treatment of BE. Both studies included patients with BE scheduled for their first focal ablation therapy, the RFA study enrolled patients between March 2015 and July 2016 and the CBA study between March 2016 and November 2016. In both studies, all visible BE was ablated, combined with a circumferential treatment of the esophagogastric junction. In both trials, pain was assessed 2 hours after treatment (D0) and 2 days after treatment (D2), using a pain score ranging from 0 (“no pain”) to 10 (“worst pain possible”). Double dose PPI was prescribed to all patients after treatment. The use of pain medication was recorded. At D0 and D2, median pain scores were calculated for RFA and CBA. Additionally, patients were subdivided into two groups based on the clinically relevant cut-off pain scores 3 (mild pain) versus >3 (severe pain). Results: A total of 96 patients were included (79 with focal RFA; 17 with CBA) and median BE length was similar for the two groups (both C0M2). The majority of CBA patients had LGD as worst histology prior to treatment, whereas HGD was the most common indication in the RFA group (p<0.01). No other baseline characteristics were significantly different between the two groups (table 1). At D0, median pain scores were higher for patients after CBA than after RFA (4 (IQR) 2-5.5) vs 0 (IQR 0-3); P<0.01). At D0, 53% of CBA patients reported severe pain compared to 24% of RFA patients (OR 3.55 (95% CI 1.2010.49); P0.02). Inversely, at D2, median pain scores were lower after CBA compared to RFA (1 (IQR 0-2) vs 3 (IQR 1-5); P0.02). At D2, 18% of CBA patients had severe pain compared to 46% of the RFA patients (OR 0.26 (95% CI 0.07-0.96); P0.03). The number of patients using oral analgesics at D2 was not significantly different between both groups. Conclusion: In this post-hoc analysis of two prospective studies, CBA was associated with significantly less pain 2 days after treatment whereas direct post-procedural pain was worse compared to RFA. Implications: Our results might indicate a more protracted pain course after RFA compared to CBA. This may potentially lead to a delay in resumption of normal activities. A randomized study is required to draw firmer conclusions.
Baseline characteristics
Table 1 Factor Age (years) Male gender Caucasian race Size of hiatal hernia (cm) Length of BE (cm) Worst Histology in Flat mucosa on Index endoscopy . No metaplasia . Non-dysplastic BE . LGD . HGD . Cancer . Squamous cell cancer Spatial distribution of worst dysplasia Multifocal LGD Multifocal HGD Multifocal Cancer
BE with Flat dysplasia (NZ34) 63.5[55.0,73.0] 28(82.4) 34(100.0) 2.0[1.00,4.0] 4.0[1.00,4.0]
BE with Visible Lesion (NZ230) 63.5[55.0,71.0] 204(88.7) 221(96.5) 3.0[2.0,4.0] 5.0[3.0,8.0]
0(0.0) 4(11.8) 20(58.8) 10(29.4) 0(0.0) 0(0.0) 0.71[0.00,1.00]
5(2.6) 25(13.0) 40(20.8) 99(51.6) 22(11.5) 1(0.52) 0.60[0.00,1.00]
8(40.0) 0(0.0) ——
12(30.0) 14(14.1) 1(4.5)
p-value
Gender Age, mean
Male, n (%) Years (SD)
0.58b 0.29c 0.75c 0.30b 0.002b <0.001c
Worst diagnosis prior to treatment (in biopsies or ER specimens) Prior treatment
LGD, n(%) HGD, n(%) EAC, n(%)
BE length prior to focal treatment, median
0.52b 0.44c 0.20c
Statistics presented as Mean SD, Median [P25,P75] or N (column %). p-values: aZANOVA, bZKruskal-Wallis test, cZPearson’s chi-square test, dZFisher’s Exact test
Tu1186 Post-Procedural Pain Associated With Endoscopic Ablation Therapy of Barrett’s Esophagus: Post-Hoc Comparison Between Radiofrequency Ablation and Cryoballoon Ablation Sanne N. van Munster*1, Hannah Künzli1,2, Jacques Bergman1, Bas L. Weusten2,1 1 Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, Netherlands; 2Gastroenterology & Hepatology, Sint Antonius Hospital, Nieuwegein, Netherlands
AB574 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
ER, n(%) cRFA, n(%) Circumferential, cm (IQR) Maximum, cm (IQR)
CBA (NZ17) 14 (82) 67 (6271) 9 (53) 1 (6) 7 (41)
RFA (NZ79) 71 (89) 65 (5973) 23 (29) 39 (49) 17 (22)
Pvalue 0.38 0.70
8 (47) 6 (35) 0 (0-0)
35 (44) 34 (43) 0 (0-0)
0.84 0.56 0.47
2 (1-3)
2 (1-2)
0.31
<0.01
BE Z Barrett’s Esophagus; CBA Z CryoBalloon Ablation; cRFA Z circumferential RFA; ER Z endoscopic resection; HGD Z High-grade dysplasia; LGD Z Low-grade dysplasia; M-EAC Z Mucosal Esophageal Adenocarcinoma; RFA Z RadioFrequency Ablation
Tu1187 Influence of Submucosal Tunneling Endoscopic Resection on Esophageal Motility Parameters Mengdie Tang*1,2, Xueliang Li1 1 Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu Province, China; 2 Department of Gastroenterlogy, Anhui Province Hospital, Hefei, Anhui, China Introduction Submucosal tunneling endoscopic resection (STER), as a new treatment to esophagus submucosal tumors (SMTs), attracts broad attention. But it may cause inflammation, adhesions and atrophy of the esophageal submucosa and cause the destroy of the muscularis propria where the tumor existed, these may induce an injure of the esophageal motor. Therefore, the aim of this study was to elucidate the effect of STER on esophageal motility. Methods: A total of 12 patients with esophagus submucosal tumors were selected in our study. The differences of high-resolution manometry (HRM) results were compared before and 3 months after STER. The paired t-test was used for normally distributed measurement data comparisons. Wilcoxon-test was performed for non- normally distributed
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Tu1185 Flat Dysplasia Is Preferentially Localized to the Proximal Segment of Barrett’s Esophagus: A Single Center Study of 264 Patients Tanmayee Benjamin*1, Deepa T. Patil2, Ilyssa Gordon2, John R. Goldblum2, Madhusudhan R. Sanaka1, Rocio Lopez3, John J. Vargo1, Prashanthi N. Thota1 1 Digestive Disease Institute, Cleveland Clinic Foundation, Cleveland, OH; 2 Pathology, Cleveland Clinic Foundation, Cleveland, OH; 3Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, OH Background: Although dysplasia continues to be the best available biomarker of Barrett’s esophagus (BE) neoplastic progression, it is frequently flat and patchy in distribution, supporting the rationale for surveillance with random four quadrant biopsies taken at each centimeter of BE. The goal of this study was to systematically assess the spatial distribution of flat dysplasia in BE segment and compare the findings with a cohort of patients with endoscopically visible lesions (VL). Methods: BE patients referred for endoscopic eradication therapy (EET) between 2011 and 2015 were categorized into those with flat dysplasia (study group) and those who had VL prior to or during EET (comparison group). Demographic data, detailed endoscopic findings including length of the BE segment, hiatal hernia size, endoscopic level of biopsy and histological findings were reviewed. The location of dysplasia was standardized based on the length of BE segment. Top of the gastric folds was assigned a value of 0, maximal extent of squamocolumnar junction, a value of 1 and midpoint of BE segment was assigned 0.5. In cases of multifocal dysplasia, the lowest level is used for calculation. Results: Of the total 264 patients, 34 patients formed the study group (median age: 65 years; M:F : 5:1) and 230 belonged to the comparison group (Table 1). The study group had shorter BE segments. Majority of the patients in study group showed low grade dysplasia (LGD), while those in the comparison group showed high grade dysplasia (HGD) or cancer (Table 1; p<0.001). There were no significant demographic differences between flat dysplasia group and VL group. In half of the study group, the worst grade of dysplasia was found in the proximal third of BE segment. In the comparison group, the worst dysplasia was located in the proximal two-fifths of the BE segment (location in flat dysplasia group 0.71, VL group 0.6). While multifocal LGD was seen in both the groups, multifocal HGD was only observed in the comparison group. Conclusions: Flat dysplasia is preferentially located in the proximal segment of BE and is predominantly low-grade in morphology. This finding suggests that in patients referred for EET, aggressive sampling of the proximal BE segment may reveal additional foci of dysplasia and influence endoscopic management.
Introduction: Radiofrequency ablation (RFA) has been shown to be safe and effective for eradication of Barrett’s Esophagus (BE), but is associated with significant pain in a proportion of patients. As an alternative, CryoBalloon ablation (CBA) has recently been developed. In contrast to heat-based ablation technology, CBA preserves the extracellular matrix which might be associated with less pain while maintaining sufficient depth of ablation. Aim: To compare post-procedural pain between focal RFA and CBA Methods: This post-hoc analysis was performed on pain scores derived from two separate prospective studies assessing the safety and efficacy of RFA and CBA respectively, for the treatment of BE. Both studies included patients with BE scheduled for their first focal ablation therapy, the RFA study enrolled patients between March 2015 and July 2016 and the CBA study between March 2016 and November 2016. In both studies, all visible BE was ablated, combined with a circumferential treatment of the esophagogastric junction. In both trials, pain was assessed 2 hours after treatment (D0) and 2 days after treatment (D2), using a pain score ranging from 0 (“no pain”) to 10 (“worst pain possible”). Double dose PPI was prescribed to all patients after treatment. The use of pain medication was recorded. At D0 and D2, median pain scores were calculated for RFA and CBA. Additionally, patients were subdivided into two groups based on the clinically relevant cut-off pain scores 3 (mild pain) versus >3 (severe pain). Results: A total of 96 patients were included (79 with focal RFA; 17 with CBA) and median BE length was similar for the two groups (both C0M2). The majority of CBA patients had LGD as worst histology prior to treatment, whereas HGD was the most common indication in the RFA group (p<0.01). No other baseline characteristics were significantly different between the two groups (table 1). At D0, median pain scores were higher for patients after CBA than after RFA (4 (IQR) 2-5.5) vs 0 (IQR 0-3); P<0.01). At D0, 53% of CBA patients reported severe pain compared to 24% of RFA patients (OR 3.55 (95% CI 1.2010.49); P0.02). Inversely, at D2, median pain scores were lower after CBA compared to RFA (1 (IQR 0-2) vs 3 (IQR 1-5); P0.02). At D2, 18% of CBA patients had severe pain compared to 46% of the RFA patients (OR 0.26 (95% CI 0.07-0.96); P0.03). The number of patients using oral analgesics at D2 was not significantly different between both groups. Conclusion: In this post-hoc analysis of two prospective studies, CBA was associated with significantly less pain 2 days after treatment whereas direct post-procedural pain was worse compared to RFA. Implications: Our results might indicate a more protracted pain course after RFA compared to CBA. This may potentially lead to a delay in resumption of normal activities. A randomized study is required to draw firmer conclusions.
Baseline characteristics
Table 1 Factor Age (years) Male gender Caucasian race Size of hiatal hernia (cm) Length of BE (cm) Worst Histology in Flat mucosa on Index endoscopy . No metaplasia . Non-dysplastic BE . LGD . HGD . Cancer . Squamous cell cancer Spatial distribution of worst dysplasia Multifocal LGD Multifocal HGD Multifocal Cancer
BE with Flat dysplasia (NZ34) 63.5[55.0,73.0] 28(82.4) 34(100.0) 2.0[1.00,4.0] 4.0[1.00,4.0]
BE with Visible Lesion (NZ230) 63.5[55.0,71.0] 204(88.7) 221(96.5) 3.0[2.0,4.0] 5.0[3.0,8.0]
0(0.0) 4(11.8) 20(58.8) 10(29.4) 0(0.0) 0(0.0) 0.71[0.00,1.00]
5(2.6) 25(13.0) 40(20.8) 99(51.6) 22(11.5) 1(0.52) 0.60[0.00,1.00]
8(40.0) 0(0.0) ——
12(30.0) 14(14.1) 1(4.5)
p-value
Gender Age, mean
Male, n (%) Years (SD)
0.58b 0.29c 0.75c 0.30b 0.002b <0.001c
Worst diagnosis prior to treatment (in biopsies or ER specimens) Prior treatment
LGD, n(%) HGD, n(%) EAC, n(%)
BE length prior to focal treatment, median
0.52b 0.44c 0.20c
Statistics presented as Mean SD, Median [P25,P75] or N (column %). p-values: aZANOVA, bZKruskal-Wallis test, cZPearson’s chi-square test, dZFisher’s Exact test
Tu1186 Post-Procedural Pain Associated With Endoscopic Ablation Therapy of Barrett’s Esophagus: Post-Hoc Comparison Between Radiofrequency Ablation and Cryoballoon Ablation Sanne N. van Munster*1, Hannah Künzli1,2, Jacques Bergman1, Bas L. Weusten2,1 1 Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, Netherlands; 2Gastroenterology & Hepatology, Sint Antonius Hospital, Nieuwegein, Netherlands
AB574 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
ER, n(%) cRFA, n(%) Circumferential, cm (IQR) Maximum, cm (IQR)
CBA (NZ17) 14 (82) 67 (6271) 9 (53) 1 (6) 7 (41)
RFA (NZ79) 71 (89) 65 (5973) 23 (29) 39 (49) 17 (22)
Pvalue 0.38 0.70
8 (47) 6 (35) 0 (0-0)
35 (44) 34 (43) 0 (0-0)
0.84 0.56 0.47
2 (1-3)
2 (1-2)
0.31
<0.01
BE Z Barrett’s Esophagus; CBA Z CryoBalloon Ablation; cRFA Z circumferential RFA; ER Z endoscopic resection; HGD Z High-grade dysplasia; LGD Z Low-grade dysplasia; M-EAC Z Mucosal Esophageal Adenocarcinoma; RFA Z RadioFrequency Ablation
Tu1187 Influence of Submucosal Tunneling Endoscopic Resection on Esophageal Motility Parameters Mengdie Tang*1,2, Xueliang Li1 1 Department of Gastroenterology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu Province, China; 2 Department of Gastroenterlogy, Anhui Province Hospital, Hefei, Anhui, China Introduction Submucosal tunneling endoscopic resection (STER), as a new treatment to esophagus submucosal tumors (SMTs), attracts broad attention. But it may cause inflammation, adhesions and atrophy of the esophageal submucosa and cause the destroy of the muscularis propria where the tumor existed, these may induce an injure of the esophageal motor. Therefore, the aim of this study was to elucidate the effect of STER on esophageal motility. Methods: A total of 12 patients with esophagus submucosal tumors were selected in our study. The differences of high-resolution manometry (HRM) results were compared before and 3 months after STER. The paired t-test was used for normally distributed measurement data comparisons. Wilcoxon-test was performed for non- normally distributed
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