- Email: [email protected]
Tu1192 Comparative Study of Esophageal Stent and Percutaneous Gastrostomy for Dysphagia Caused By Esophageal Cancer
Abstracts
should be on targeted intervention to improve treatment outcomes in patients of lower socio-economic status with EC.
Figure showing rising rates in terms of percentage change from 1992-1995 to 2010-2012 of different indices related to race and socio-economic health disparity in patient of esophageal adenocarcinoma (left panel) and squamous cell cancer (right panel).
Tu1190 Minimum Criteria of Narrow Band Imaging Magnification Endoscopy for the Detection of Superficial Esophageal Squamous Cell Carcinoma: A Randomized Controlled Trial Akira Dobashi*1, Kenichi Goda1, Kazuki Sumiyama1, Yuko Hara1, Shinichi Hirooka2, Shigeharu Hamatani2, Masahiro Ikegami2, Hisao Tajiri1 1 Endoscopy, The Jikei University School of Medicine, Tokyo, Japan; 2 Pathology, The Jikei University School of Medicine, Tokyo, Japan Background and Aim: The diagnostic accuracy of Narrow Band Imaging magnification endoscopy (NBI-ME) for superficial esophageal squamous cell carcinoma (SESCC), including high-grade intraepithelial neoplasia, has been reported to be significantly higher than that of white light endoscopy (WLE). NBI-ME is, however, a time-consuming procedure and not widely used, because it necessitates assessment of many NBI-ME findings (total Z 6; 4 pertaining to the morphological changes in the intraepithelial papillary capillary loop [IPCL], and 2 other NBI-ME features as follows: dilatation, tortuosity, caliber change, various shapes [VS], increase in the number of IPCL [INI], and intervascular background coloration). According to our randomized controlled trial data, we created the minimum criteria consisting of VS and INI by using stepwise statistical methods. The preliminary study showed that the minimum criteria include diagnostic performance comparable to that of the conventional criteria that consisted of the 4 morphological changes of IPCL. This study aimed to validate the real-time diagnostic utility of NBI-ME, as compared to WLE, according to the minimum criteria. Patients and Methods: Two experts randomly examined 170 patients with a history of head and neck cancer or SESCCs. One endoscopist performed WLE, and the other performed NBI-ME using a dual focus scope (DFS; Olympus Corporation, Tokyo, Japan). Endoscopically biopsied specimens were obtained from a suspected SESCC lesion during WLE, or from a brownish area (diameter, >5 mm) during NBI. As controls, biopsy specimens from a normal mucosal site near the suspected SESCC lesion were obtained. The endoscopists evaluated the lesions for the 6 NBI-ME findings. The primary endpoint was to evaluate the real-time detection rates of SESCC by WLE and NBI-ME according to the minimum criteria. The secondary endpoint was to assess the diagnostic performance of the 2 endoscopic techniques. Results: Of 156 suspected SESCC lesions, 77 were histologically diagnosed as SESCC. The detection rates for SESCC by NBI-ME according to the minimum criteria were significantly higher than those by WLE (90.9% vs. 50.6%, P < 0.01). The area under the receiver operating characteristic curve based on the minimum and conventional criteria did not differ significantly (0.92, 95% confidence interval [CI] Z 0.88–0.96 and 0.91, 95% CI Z 0.87–0.95, respectively). Conclusion: Our results show that the minimum criteria-based NBI-ME diagnosis of SESCC using a DFS has clinical utility and may be applied in routine practice.
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Tu1191 Safety and Technical Feasibility of Endoscopic Placement of Esophageal Self- Expandable Metal Stents Without the Aid of Fluoroscopy Shreyas Saligram*1, Diego Lim2, Luis pena1, Mark Friedman1, Cynthia L. Harris1, Jason B. Klapman1 1 GI, Moffitt Cancer Center, Tampa, FL; 2Internal Medicine, Kansas University Medical Center, Kansas City, KS Background: Endoscopic placement of Esophageal Self-expandable Metal Stents (SEMS) has become the gold standard for treatment of malignant dysphagia. Other indications include benign esophageal conditions like management of dysphagia secondary to anastomotic strictures, treatment of tracheo-esophageal fistulas and post- surgical esophageal leaks. Traditionally, esophageal stents have been placed with the aid of fluoroscopy. At our institution, we have been placing SEMS without the aid of fluoroscopy. Our aim was to evaluate the safety and feasibility of direct endoscopic placement of esophageal SEMS. Methods: A retrospective review was performed to identify all patients who underwent esophageal SEMS from January 2010 to June 2015 in our institution. Medical records were reviewed to obtain information on demographic, clinical and outcome data. Placement of all SEMS was accomplished under direct endoscopic visualization without fluoroscopy. When the indication was for benign or malignant stricture, all attempts to traverse the stricture were made to document the exact length of the stricture. The exact size of the stent chosen depended on length of the lesion and the lumen diameter with the goal of choosing a stent length with proximal end 2 cms above and distal end 2 cms below the lesion. Misplacement of the stent during the procedure that required removal of the stent and placement of another new stent was considered as a failed procedure. Adverse events due to SEMS placement that occurred in the first 48 hours of the procedure were documented. Results: A total of 172 patients underwent 280 procedures for SEMS placement. Mean age was 66 years (IQR 33-94; SD +/- 9). The majority of patients were male 132 (77%).The most common indication for SEMS placement was stricture in 248 (88%) of the procedures. The indications for which SEMS was placed and its related complications are shown in Table 1. The mean location of stricture was at 30cm (IQR 16-46; SD +/- 6.5) and the mean length of the stricture was 5.2cm (IQR 1-25; SD +/- 3.6). Initial dilation of the stricture prior to stent placement was performed in 111/280(40%) of cases. The mean length of SEMS was 90cm (IQR 40-120) and diameter was 15mm (IQR 10-22). A total of 29 (10%) patients had more than one stent placed to bridge the stricture. Number of patients who had periprocedure SEMS misplacement was 8 (3%). However, only 4 (1.5%) patients needed to have a new stent placed during the same procedure. In the remainder of the patients with misplacement, the stent could be repositioned during the procedure without the need for a new stent. Conclusion: Based on our experience, esophageal SEMS can be placed accurately and safely under direct endoscopic visualization without the aid of fluoroscopy. The technique simplifies the procedure and allows stent placement to be performed in any endoscopy room. Table 1. Indications for SEMS placement with associated complications Indication Adenocarcinoma cancer recurrence post surgery Anastamotic leak Anastamotic stricture Benign stricture Bronchoesophageal fistula Perforation Stricture due to squamous cell carcinoma Stricture due to adenocarcinoma Stricture due to external compression Stricture due to radiation therapy Tracheoesophageal fistula Total
Procedures-n (%)
Stent Misplacement-n (%)
6 (2.1)
1 (0.4)
2 (0.7) 47 (16.8) 1 (0.4) 2 (0.7) 5 (1.8) 28 (10) 155 (55.4) 10 (3.6) 1 (0.4) 23 (8.2) 280
0 1 (0.4) 0 0 0 1 (0.4) 4 (1.5) 1 (0.4) 0 0 8 (3)
Tu1192 Comparative Study of Esophageal Stent and Percutaneous Gastrostomy for Dysphagia Caused By Esophageal Cancer Ji Hye Jung*, Sun Hwa Kim, Inseub Shin, Yang Won Min, Byung-Hoon Min, Jun Haeng Lee, Poong-Lyul Rhee, Jae J. Kim Department of Medicine, Samsung Medical Center, Seoul, Gangnam-Gu, Korea (the Republic of) Background/Aim: Esophageal stent and percutaneous gastrostomy have been the common treatment method for patients with dysphagia caused by esophageal cancer. This study aimed to compare the prognosis of patients receiving esophageal stent and those receiving gastrostomy. Method: We retrospectively reviewed a total of 151 esophageal cancer patients who received either esophageal stent (stent group) or gastrostomy (gastrostomy group) for initial treatment procedure for
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB569
Abstracts
dysphagia between Jan 2008 and Dec 2013. Patients who received procedure due to bronchoesophageal fistula (nZ11) and radiation induced stricture (nZ1) were excluded from the analysis. The overall survival and other clinical data according to additional intervention and complications were compared between the two groups. Result: Finally a total of 137 patients were analyzed. Among them, 83 patients (60.6%) received esophageal stent and 54 (39.4%) did gastrostomy. There were no significant differences in age, tumor histology, and obstruction length. However, stent group had more male and advanced stage patients than gastrostomy group. Although chemotherapy was similarly performed between the two groups, radiation treatment and surgical operation was more frequently performed in the gastrostomy group than in the stent group (81.4% vs. 33.8%, P < 0.001 and 22.2% vs. 8.4%, P Z 0.031, respectively). Cox regression analysis showed marginal survival benefit in the gastrostomy group than in the stent group (hazard ratio 0.574, 95% confidence interval 0.322-1.022, P Z 0.059). Additional intervention was more frequently required in the stent group than in the gastrostomy group (28.9% vs. 3.7%, P < 0.001). However, there was no significant difference in procedure-related complication. Conclusion: Our data suggested that percutaneous gastrostomy would have a marginal survival benefit compared with esophageal stent for relieving dysphagia by esophageal cancer. In addition, gastrostomy has an additional advantage of less needs for additional intervention.
Tu1193 Liquid Nitrogen Spray Cryotherapy Use for Dysphagia Palliation in Patients With Unresectable Esophageal Cancer: A Retrospective Multicenter Outcomes Study Toufic Kachaamy*, Raman Battish, Jeffrey Weber, Scott Hendrickson, Ravi K. Prakash, Rajeev Nayar, Trisha DaSilva DaSilva, Digant Gupta, Pankaj Vashi Gastroenterology, Cancer Treatment Center of America, Phoenix, AZ Introduction: Dysphagia (DP) is a debilitating symptom in patients with unresectable esophageal cancer (EsoCa) contributing to poor quality of life and worsening nutritional status. The two most commonly used palliative modalities for DP are radiation therapy (RT) and esophageal stenting. However, RT is limited by adverse events (AEs) and total dose, and stenting suffers from a high rate of reflux, migration and chest pain. A relatively new modality, liquid nitrogen endoscopic spray cryotherapy (cryo) has been described as salvage when other options have been exhausted. Currently, there is no data available on the safety and efficacy of this modality in relieving DP in context of palliative chemotherapy. We present here our experience from 4 cancer centers where cryo was used relatively early for DP palliation in unresectable EsoCa. Methods: A retrospective consecutive case series of 37 unresectable EsoCA patients undergoing palliative liquid nitrogen endoscopic cryotherapy from May 2014 to Oct 2015. Each tumor site was treated for 20-30 seconds for 2-3 cycles with at least 45 seconds between freezes to allow complete tissue thawing. The primary outcomes were change in DP scores between pre- and post-cryo and AEs. DP was measured using a 4-point Likert scale: 0, no dysphagia; 1, dysphagia to solids; 2, dysphagia to semi-solids; 3, dysphagia to liquids; 4, dysphagia to own saliva. Paired t-tests were used to evaluate changes in DP scores. Results: There were 30 males and 7 females. Mean age was 57.3 yrs. 4 patients had stage II disease, 7 stage III, 23 stage IV and 3 undetermined. Among 37 patients, a total of 86 cryo treatments were delivered (mean treatments per patient, 2.3; range 1-7). Table 1 displays the characteristics of these 86 treatments. A total of 49/86 (57%) treatments were performed within 30 days of chemotherapy treatment (CMT). As shown in Table 2, the mean DP score improved significantly from 2.5 pre-cryo to 1.7 postcryo (decline of 0.8 points; p<0.001). Patients <60 yrs demonstrated a significantly greater decline in DP score compared to those >Z 60 yrs (DP decline of 1.0 and 0.50 respectively; pZ0.007). Although not statistically significant, patients receiving CMT demonstrated a greater decline in DP score compared to those without CMT (DP decline of 0.90 and 0.70 respectively; pZ0.40). A total of 5/86 (6%) treatments were associated with very minor AEs (1 episode of moderate chest pain and 4 episodes of minimal chest pain not associated with the therapy). No CTCAE adverse events greater or equal to 2 were seen. Conclusion: Liquid nitrogen spray cryotherapy appears to be safe and effective for DP palliation in unresectable esophageal cancer even in patients actively receiving chemotherapy. Large prospective studies are needed to determine if this should be a paradigm shift in management of DP in esophageal cancer. Table 1. Characteristics of Cryotherapy Treatments (N[86) Characteristic Number of sites treated Number of cycles per site Freeze time in seconds per cycle
Mean (Standard Deviation) Median Range 2.6 (1.7) 2.6 (0.64) 23.6 (4.8)
2 3 20
1-11 1-4 15-30
AB570 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
Table 2. Change in Dysphagia score (DP) between Pre- and PostCryotherapy (N[86) Patients All patients Age Age <60 Age >60 Concurrent Chemotherapy (CMT) CMT yes CMT no
Pre-cryo DP score
Post-cryo DP score
DP score difference
2.5
1.7
0.8
2.7 2.4
1.7 1.9
1.0 1.0
2.6 2.5
1.7 1.8
0.9 0.7
P-value < 0.001 0.007
0.4
Tu1194 Liquid Nitrogen Spray Cryotherapy (SCT) Based Multimodal Endoscopic Management of Dysplastic Barrett’s and Foregut Neoplasia: Retrospective Review and Long Term Follow-up at a Single Tertiary Care Referral Center Shivangi Kothari*, Krystle Bittner, Asad Ullah, Vivek Kaul Div of Gastroenterology/Hepatology, University of Rochester Medical Center, Rochester, NY Background: Endoscopic management of dysplastic Barrett’s esophagus (BE) and foregut (esophageal & gastric) neoplasia has emerged as an effective treatment. Data for role of SCT in this setting is limited. We reviewed our experience with SCT based endoscopic management of esophageal and gastric neoplasia for a consecutive cohort of patients undergoing curative and palliative intent endotherapy. We aimed to evaluate the safety and long term outcomes of SCT based multimodality therapy in the management of dysplastic BE and foregut neoplasia. Methods: We retrospectively reviewed the endoscopic cryotherapy database at our center from August 2008 to June 2015. 50 patients underrwent SCT (curative or palliative intent) for dysplastic BE(nZ14),esophageal and GE junction adenocarcinoma (nZ14 T1a; nZ18 T1b or higher), cardia cancer (nZ3) and squamous papilloma of esophagus(nZ1). Patient demographics, disease characteristics, treatment details and long term outcomes were recorded. Complete eradication of intestinal metaplasia (CEIM), where applicable, was defined as 2 consecutive negative forceps biopsies (all patients) with at least one negative wide area transepithelial sampling (WATS-3D) brush biopsy (done in 55% patients). The study was IRB approved. Results: Mean patient age was 71.7 years; all Caucasians, 86% male.Total of 177 SCT procedures were performed in 50 patients. Mean duration of overall follow up was 3.3 years. 34/50 (68%) patients underwent spray cryotherapy with curative intent; complete follow up data available for 29 of 34 patients. Mean BE length was 6.8 cm. Complete eradication of dysplasia (CE-D) was achieved in 28/29 (96.6%) patients and CE-IM in 22/29 (75.9%). Mean post-CRIM surveillance duration was 2.3 years. 58% patients underwent radiofrequency ablation (RFA) during course of treatment, 15% of these were RFA failures. 62% also underwent endoscopic resection (EMR) as part of multimodal treatment. The remaining 16/50 patients underwent palliative SCT for advanced esophageal (nZ14) and gastric cardia (nZ2) cancer. Only 5/16 (31%) required esophageal stent placement. Mean followup for this group was 2 years. Two complications were encountered: bleeding (nZ1) and esophageal micro-perforation (nZ1), both managed conservatively. No procedure related deaths occurred. Conclusion: SCT based multimodal endotherapy can achieve very high CE-D (> 95%) and CE-IM (>75%) in a high risk population with esophageal dysplasia/ neoplasia. These CE-D/CE-IM rates are derived from Seattle protocol based rigorous sampling. WATS-3D post-ablation sampling adds further confidence to these results (performed in 55% patients since advent of WATS-3D). SCT is safe and beneficial for palliative treatment as well, allowing for stent free survival in majority of patients. Prospective registry trials will further consolidate the efficacy of SCT in this patient population.
Tu1195 Comparison of Needle Knife vs Dual Knife for Esophageal Superficial Cancers Yuka Kowazaki*, Makoto Nishimura, Miho Matsukawa Gastroenterology, Tokyo Metropolitan Geriatric Hospital and Institution of Geriatrics, Itabashi-ku, Tokyo, Japan Background: Endoscopic submucosal dissection (ESD) is being increasingly used for superficial esophageal cancers. In Japan, the Needle Knife (KD-11Q-1, Olympus, Japan) was previously used for ESD; however, it has been considered to have a high risk of perforation because of its shape, especially for esophageal lesions. Since then,
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should be on targeted intervention to improve treatment outcomes in patients of lower socio-economic status with EC.
Figure showing rising rates in terms of percentage change from 1992-1995 to 2010-2012 of different indices related to race and socio-economic health disparity in patient of esophageal adenocarcinoma (left panel) and squamous cell cancer (right panel).
Tu1190 Minimum Criteria of Narrow Band Imaging Magnification Endoscopy for the Detection of Superficial Esophageal Squamous Cell Carcinoma: A Randomized Controlled Trial Akira Dobashi*1, Kenichi Goda1, Kazuki Sumiyama1, Yuko Hara1, Shinichi Hirooka2, Shigeharu Hamatani2, Masahiro Ikegami2, Hisao Tajiri1 1 Endoscopy, The Jikei University School of Medicine, Tokyo, Japan; 2 Pathology, The Jikei University School of Medicine, Tokyo, Japan Background and Aim: The diagnostic accuracy of Narrow Band Imaging magnification endoscopy (NBI-ME) for superficial esophageal squamous cell carcinoma (SESCC), including high-grade intraepithelial neoplasia, has been reported to be significantly higher than that of white light endoscopy (WLE). NBI-ME is, however, a time-consuming procedure and not widely used, because it necessitates assessment of many NBI-ME findings (total Z 6; 4 pertaining to the morphological changes in the intraepithelial papillary capillary loop [IPCL], and 2 other NBI-ME features as follows: dilatation, tortuosity, caliber change, various shapes [VS], increase in the number of IPCL [INI], and intervascular background coloration). According to our randomized controlled trial data, we created the minimum criteria consisting of VS and INI by using stepwise statistical methods. The preliminary study showed that the minimum criteria include diagnostic performance comparable to that of the conventional criteria that consisted of the 4 morphological changes of IPCL. This study aimed to validate the real-time diagnostic utility of NBI-ME, as compared to WLE, according to the minimum criteria. Patients and Methods: Two experts randomly examined 170 patients with a history of head and neck cancer or SESCCs. One endoscopist performed WLE, and the other performed NBI-ME using a dual focus scope (DFS; Olympus Corporation, Tokyo, Japan). Endoscopically biopsied specimens were obtained from a suspected SESCC lesion during WLE, or from a brownish area (diameter, >5 mm) during NBI. As controls, biopsy specimens from a normal mucosal site near the suspected SESCC lesion were obtained. The endoscopists evaluated the lesions for the 6 NBI-ME findings. The primary endpoint was to evaluate the real-time detection rates of SESCC by WLE and NBI-ME according to the minimum criteria. The secondary endpoint was to assess the diagnostic performance of the 2 endoscopic techniques. Results: Of 156 suspected SESCC lesions, 77 were histologically diagnosed as SESCC. The detection rates for SESCC by NBI-ME according to the minimum criteria were significantly higher than those by WLE (90.9% vs. 50.6%, P < 0.01). The area under the receiver operating characteristic curve based on the minimum and conventional criteria did not differ significantly (0.92, 95% confidence interval [CI] Z 0.88–0.96 and 0.91, 95% CI Z 0.87–0.95, respectively). Conclusion: Our results show that the minimum criteria-based NBI-ME diagnosis of SESCC using a DFS has clinical utility and may be applied in routine practice.
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Tu1191 Safety and Technical Feasibility of Endoscopic Placement of Esophageal Self- Expandable Metal Stents Without the Aid of Fluoroscopy Shreyas Saligram*1, Diego Lim2, Luis pena1, Mark Friedman1, Cynthia L. Harris1, Jason B. Klapman1 1 GI, Moffitt Cancer Center, Tampa, FL; 2Internal Medicine, Kansas University Medical Center, Kansas City, KS Background: Endoscopic placement of Esophageal Self-expandable Metal Stents (SEMS) has become the gold standard for treatment of malignant dysphagia. Other indications include benign esophageal conditions like management of dysphagia secondary to anastomotic strictures, treatment of tracheo-esophageal fistulas and post- surgical esophageal leaks. Traditionally, esophageal stents have been placed with the aid of fluoroscopy. At our institution, we have been placing SEMS without the aid of fluoroscopy. Our aim was to evaluate the safety and feasibility of direct endoscopic placement of esophageal SEMS. Methods: A retrospective review was performed to identify all patients who underwent esophageal SEMS from January 2010 to June 2015 in our institution. Medical records were reviewed to obtain information on demographic, clinical and outcome data. Placement of all SEMS was accomplished under direct endoscopic visualization without fluoroscopy. When the indication was for benign or malignant stricture, all attempts to traverse the stricture were made to document the exact length of the stricture. The exact size of the stent chosen depended on length of the lesion and the lumen diameter with the goal of choosing a stent length with proximal end 2 cms above and distal end 2 cms below the lesion. Misplacement of the stent during the procedure that required removal of the stent and placement of another new stent was considered as a failed procedure. Adverse events due to SEMS placement that occurred in the first 48 hours of the procedure were documented. Results: A total of 172 patients underwent 280 procedures for SEMS placement. Mean age was 66 years (IQR 33-94; SD +/- 9). The majority of patients were male 132 (77%).The most common indication for SEMS placement was stricture in 248 (88%) of the procedures. The indications for which SEMS was placed and its related complications are shown in Table 1. The mean location of stricture was at 30cm (IQR 16-46; SD +/- 6.5) and the mean length of the stricture was 5.2cm (IQR 1-25; SD +/- 3.6). Initial dilation of the stricture prior to stent placement was performed in 111/280(40%) of cases. The mean length of SEMS was 90cm (IQR 40-120) and diameter was 15mm (IQR 10-22). A total of 29 (10%) patients had more than one stent placed to bridge the stricture. Number of patients who had periprocedure SEMS misplacement was 8 (3%). However, only 4 (1.5%) patients needed to have a new stent placed during the same procedure. In the remainder of the patients with misplacement, the stent could be repositioned during the procedure without the need for a new stent. Conclusion: Based on our experience, esophageal SEMS can be placed accurately and safely under direct endoscopic visualization without the aid of fluoroscopy. The technique simplifies the procedure and allows stent placement to be performed in any endoscopy room. Table 1. Indications for SEMS placement with associated complications Indication Adenocarcinoma cancer recurrence post surgery Anastamotic leak Anastamotic stricture Benign stricture Bronchoesophageal fistula Perforation Stricture due to squamous cell carcinoma Stricture due to adenocarcinoma Stricture due to external compression Stricture due to radiation therapy Tracheoesophageal fistula Total
Procedures-n (%)
Stent Misplacement-n (%)
6 (2.1)
1 (0.4)
2 (0.7) 47 (16.8) 1 (0.4) 2 (0.7) 5 (1.8) 28 (10) 155 (55.4) 10 (3.6) 1 (0.4) 23 (8.2) 280
0 1 (0.4) 0 0 0 1 (0.4) 4 (1.5) 1 (0.4) 0 0 8 (3)
Tu1192 Comparative Study of Esophageal Stent and Percutaneous Gastrostomy for Dysphagia Caused By Esophageal Cancer Ji Hye Jung*, Sun Hwa Kim, Inseub Shin, Yang Won Min, Byung-Hoon Min, Jun Haeng Lee, Poong-Lyul Rhee, Jae J. Kim Department of Medicine, Samsung Medical Center, Seoul, Gangnam-Gu, Korea (the Republic of) Background/Aim: Esophageal stent and percutaneous gastrostomy have been the common treatment method for patients with dysphagia caused by esophageal cancer. This study aimed to compare the prognosis of patients receiving esophageal stent and those receiving gastrostomy. Method: We retrospectively reviewed a total of 151 esophageal cancer patients who received either esophageal stent (stent group) or gastrostomy (gastrostomy group) for initial treatment procedure for
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB569
Abstracts
dysphagia between Jan 2008 and Dec 2013. Patients who received procedure due to bronchoesophageal fistula (nZ11) and radiation induced stricture (nZ1) were excluded from the analysis. The overall survival and other clinical data according to additional intervention and complications were compared between the two groups. Result: Finally a total of 137 patients were analyzed. Among them, 83 patients (60.6%) received esophageal stent and 54 (39.4%) did gastrostomy. There were no significant differences in age, tumor histology, and obstruction length. However, stent group had more male and advanced stage patients than gastrostomy group. Although chemotherapy was similarly performed between the two groups, radiation treatment and surgical operation was more frequently performed in the gastrostomy group than in the stent group (81.4% vs. 33.8%, P < 0.001 and 22.2% vs. 8.4%, P Z 0.031, respectively). Cox regression analysis showed marginal survival benefit in the gastrostomy group than in the stent group (hazard ratio 0.574, 95% confidence interval 0.322-1.022, P Z 0.059). Additional intervention was more frequently required in the stent group than in the gastrostomy group (28.9% vs. 3.7%, P < 0.001). However, there was no significant difference in procedure-related complication. Conclusion: Our data suggested that percutaneous gastrostomy would have a marginal survival benefit compared with esophageal stent for relieving dysphagia by esophageal cancer. In addition, gastrostomy has an additional advantage of less needs for additional intervention.
Tu1193 Liquid Nitrogen Spray Cryotherapy Use for Dysphagia Palliation in Patients With Unresectable Esophageal Cancer: A Retrospective Multicenter Outcomes Study Toufic Kachaamy*, Raman Battish, Jeffrey Weber, Scott Hendrickson, Ravi K. Prakash, Rajeev Nayar, Trisha DaSilva DaSilva, Digant Gupta, Pankaj Vashi Gastroenterology, Cancer Treatment Center of America, Phoenix, AZ Introduction: Dysphagia (DP) is a debilitating symptom in patients with unresectable esophageal cancer (EsoCa) contributing to poor quality of life and worsening nutritional status. The two most commonly used palliative modalities for DP are radiation therapy (RT) and esophageal stenting. However, RT is limited by adverse events (AEs) and total dose, and stenting suffers from a high rate of reflux, migration and chest pain. A relatively new modality, liquid nitrogen endoscopic spray cryotherapy (cryo) has been described as salvage when other options have been exhausted. Currently, there is no data available on the safety and efficacy of this modality in relieving DP in context of palliative chemotherapy. We present here our experience from 4 cancer centers where cryo was used relatively early for DP palliation in unresectable EsoCa. Methods: A retrospective consecutive case series of 37 unresectable EsoCA patients undergoing palliative liquid nitrogen endoscopic cryotherapy from May 2014 to Oct 2015. Each tumor site was treated for 20-30 seconds for 2-3 cycles with at least 45 seconds between freezes to allow complete tissue thawing. The primary outcomes were change in DP scores between pre- and post-cryo and AEs. DP was measured using a 4-point Likert scale: 0, no dysphagia; 1, dysphagia to solids; 2, dysphagia to semi-solids; 3, dysphagia to liquids; 4, dysphagia to own saliva. Paired t-tests were used to evaluate changes in DP scores. Results: There were 30 males and 7 females. Mean age was 57.3 yrs. 4 patients had stage II disease, 7 stage III, 23 stage IV and 3 undetermined. Among 37 patients, a total of 86 cryo treatments were delivered (mean treatments per patient, 2.3; range 1-7). Table 1 displays the characteristics of these 86 treatments. A total of 49/86 (57%) treatments were performed within 30 days of chemotherapy treatment (CMT). As shown in Table 2, the mean DP score improved significantly from 2.5 pre-cryo to 1.7 postcryo (decline of 0.8 points; p<0.001). Patients <60 yrs demonstrated a significantly greater decline in DP score compared to those >Z 60 yrs (DP decline of 1.0 and 0.50 respectively; pZ0.007). Although not statistically significant, patients receiving CMT demonstrated a greater decline in DP score compared to those without CMT (DP decline of 0.90 and 0.70 respectively; pZ0.40). A total of 5/86 (6%) treatments were associated with very minor AEs (1 episode of moderate chest pain and 4 episodes of minimal chest pain not associated with the therapy). No CTCAE adverse events greater or equal to 2 were seen. Conclusion: Liquid nitrogen spray cryotherapy appears to be safe and effective for DP palliation in unresectable esophageal cancer even in patients actively receiving chemotherapy. Large prospective studies are needed to determine if this should be a paradigm shift in management of DP in esophageal cancer. Table 1. Characteristics of Cryotherapy Treatments (N[86) Characteristic Number of sites treated Number of cycles per site Freeze time in seconds per cycle
Mean (Standard Deviation) Median Range 2.6 (1.7) 2.6 (0.64) 23.6 (4.8)
2 3 20
1-11 1-4 15-30
AB570 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
Table 2. Change in Dysphagia score (DP) between Pre- and PostCryotherapy (N[86) Patients All patients Age Age <60 Age >60 Concurrent Chemotherapy (CMT) CMT yes CMT no
Pre-cryo DP score
Post-cryo DP score
DP score difference
2.5
1.7
0.8
2.7 2.4
1.7 1.9
1.0 1.0
2.6 2.5
1.7 1.8
0.9 0.7
P-value < 0.001 0.007
0.4
Tu1194 Liquid Nitrogen Spray Cryotherapy (SCT) Based Multimodal Endoscopic Management of Dysplastic Barrett’s and Foregut Neoplasia: Retrospective Review and Long Term Follow-up at a Single Tertiary Care Referral Center Shivangi Kothari*, Krystle Bittner, Asad Ullah, Vivek Kaul Div of Gastroenterology/Hepatology, University of Rochester Medical Center, Rochester, NY Background: Endoscopic management of dysplastic Barrett’s esophagus (BE) and foregut (esophageal & gastric) neoplasia has emerged as an effective treatment. Data for role of SCT in this setting is limited. We reviewed our experience with SCT based endoscopic management of esophageal and gastric neoplasia for a consecutive cohort of patients undergoing curative and palliative intent endotherapy. We aimed to evaluate the safety and long term outcomes of SCT based multimodality therapy in the management of dysplastic BE and foregut neoplasia. Methods: We retrospectively reviewed the endoscopic cryotherapy database at our center from August 2008 to June 2015. 50 patients underrwent SCT (curative or palliative intent) for dysplastic BE(nZ14),esophageal and GE junction adenocarcinoma (nZ14 T1a; nZ18 T1b or higher), cardia cancer (nZ3) and squamous papilloma of esophagus(nZ1). Patient demographics, disease characteristics, treatment details and long term outcomes were recorded. Complete eradication of intestinal metaplasia (CEIM), where applicable, was defined as 2 consecutive negative forceps biopsies (all patients) with at least one negative wide area transepithelial sampling (WATS-3D) brush biopsy (done in 55% patients). The study was IRB approved. Results: Mean patient age was 71.7 years; all Caucasians, 86% male.Total of 177 SCT procedures were performed in 50 patients. Mean duration of overall follow up was 3.3 years. 34/50 (68%) patients underwent spray cryotherapy with curative intent; complete follow up data available for 29 of 34 patients. Mean BE length was 6.8 cm. Complete eradication of dysplasia (CE-D) was achieved in 28/29 (96.6%) patients and CE-IM in 22/29 (75.9%). Mean post-CRIM surveillance duration was 2.3 years. 58% patients underwent radiofrequency ablation (RFA) during course of treatment, 15% of these were RFA failures. 62% also underwent endoscopic resection (EMR) as part of multimodal treatment. The remaining 16/50 patients underwent palliative SCT for advanced esophageal (nZ14) and gastric cardia (nZ2) cancer. Only 5/16 (31%) required esophageal stent placement. Mean followup for this group was 2 years. Two complications were encountered: bleeding (nZ1) and esophageal micro-perforation (nZ1), both managed conservatively. No procedure related deaths occurred. Conclusion: SCT based multimodal endotherapy can achieve very high CE-D (> 95%) and CE-IM (>75%) in a high risk population with esophageal dysplasia/ neoplasia. These CE-D/CE-IM rates are derived from Seattle protocol based rigorous sampling. WATS-3D post-ablation sampling adds further confidence to these results (performed in 55% patients since advent of WATS-3D). SCT is safe and beneficial for palliative treatment as well, allowing for stent free survival in majority of patients. Prospective registry trials will further consolidate the efficacy of SCT in this patient population.
Tu1195 Comparison of Needle Knife vs Dual Knife for Esophageal Superficial Cancers Yuka Kowazaki*, Makoto Nishimura, Miho Matsukawa Gastroenterology, Tokyo Metropolitan Geriatric Hospital and Institution of Geriatrics, Itabashi-ku, Tokyo, Japan Background: Endoscopic submucosal dissection (ESD) is being increasingly used for superficial esophageal cancers. In Japan, the Needle Knife (KD-11Q-1, Olympus, Japan) was previously used for ESD; however, it has been considered to have a high risk of perforation because of its shape, especially for esophageal lesions. Since then,
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