- Email: [email protected]
Tu1200 Survey of Current Practice Patterns for Per Oral Endoscopic Myotomy (POEM)
Abstracts
Females had shorter length of BE (p< .001); and females were less likely to have dysplastic BE (p< .001). After RTBWE, females were less likely to be hospitalized (p < .02); no differences in GI bleeding or perforation rates (P>.05), or overall complications were noted (P>.5); females were almost twice as likely to develop strictures (Odds Ratio 1.7), after considering baseline level of dysplasia, race, length of BE segment, EMR treatment before RFA, age, PPI compliance, and the number of total RFA treatment sessions. In gender efficacy analysis, fewer RFA sessions were required for females to achieve complete remission of intestinal metaplasia (CRIM)(p< .001) on univariate analysis; females had a higher CRIM rate compared to males, but statistical significance was lost on multivariate analysis; no difference was found in recurrence after CRIM (P > .05); female BE patients took longer time to achieve remission after RTBWE (P < .05) when compared with males of similar age and BE length. Conclusions and Implications of Key Findings: Although this study supports the probable association between differential outcomes of BE responses to RTBWE and female gender, there is insufficient evidence to conclude this variations of gender influences. Our data call for larger examination of facilitators and barriers to sustain BE remission strategies in women.
Tu1197 Strategies for Stenosis After ESD for Early Esophageal Cancer in Our Hospital Yoshiaki Takahashi*, Shinpei Kawaguchi, Haruhiko Ozaki, Yosuke Inoue, Kazuhiro Ota, Satoshi Harada, Yuichi Kojima, Toshihisa Takeuchi, Kazuhide Higuchi Osaka Medical College, Takatsuki, Japan Background and Purpose: Currently, the usefulness of oral steroids and topical steroid injection for the prevention of stenosis after endoscopic submucosal dissection (ESD) of the esophagus is being examined. However, there have been many patients with stenosis despite its prevention; endoscopic balloon dilatation (EBD) is performed. We investigated the current status of post-ESD stenosis in our hospital and usefulness of stenting in non-responders to EBD. Methods: The subjects were 165 patients with early esophageal cancer who underwent ESD in our hospital between July 2009 and December 2015. Based on endoscopy findings the day after ESD, the extent of the post-ESD ulcer as a percentage of the esophageal circumference was classified into 4 grades: (1) <50%, (2) 50-74%, (3) 75-99%, and (4) 100%. It was examined with respect to the site, prevention methods, and presence or absence of stenosis. Furthermore, we reviewed additional treatment for non-responders to EBD. Results: Of 110 patients with post-ESD ulcers occupying <50% of the esophageal circumference, there was no stenosis in any patient. Of 32 patients with postESD ulcers occupying 50-74%, stenosis was present in 1, whereas it was absent in 31 (stenosis rate: 3%). Of 18 patients with post-ESD ulcers occupying 75-99%, stenosis was present in 10, whereas it was absent in 8 (stenosis rate: 55.5%). Of 5 patients with post-ESD ulcers occupying 100%, stenosis was present in 2, whereas it was absent in 3 (stenosis rate: 40%). For 15 patients with post-ESD ulcers occupying 7599%, topical steroid injection had been performed to prevent stenosis, but its preventive effects were not marked (stenosis was present in 9, whereas it was absent in 6, with a response rate of 40%). To 4 patients with post-ESD ulcers occupying 100%, oral steroids had been administered for prevention. Stenosis was present in 1, whereas it was absent in 3, with a response rate of 75%. Oral steroids were effective. For patients with stenosis, EBD was performed. In 10 of the 13 patients, an improvement was achieved, but stenosis treatment was difficult in the other 3 patients. For these patients, stenting was performed, followed by stent removal after 2 months. The results were evaluated. In 2 patients, an improvement in stenosis was achieved, whereas the stent was ineffective due to frequent migration in 1, requiring periodic EBD. Conclusion: In our hospital, oral steroids were more useful than topical steroid injection for preventing stenosis. Furthermore, stenting for non-responders may be useful.
Tu1198 Efficacy of Multiple Clips With Line Method for Endoscopic Submucosal Dissection of Esophageal Cancer Nobukazu Yorimitsu*, Tsuneo Oyama, Akiko Takahashi Saku Central Hospital Advanced Care Center, Saku city, Japan Background: Clip with line method was developed in 2002 by our institute, and widely accepted technique that make ESD easier1,2. However, sometimes single clip with line is not effective, when the size of target lesion was big. Aim: The aim of this retrospective study is to clarify the usefulness of multiple clips with line method for esophageal ESD. Patients and methods: A consecutive one hundred twenty four esophageal ESD from March 2014 to August 2016 treated by clip with line method were enrolled to this retrospective study. Patients characteristics, Male 112, Female12, Mean age 69 (30-91), Location Ce:6, Ut: 7, Mt:89, Lt:19, Ae:3. Macroscopic type 0-I : 3, IIa : 7, IIb : 42 and IIc : 72, Tumor size was 20.5mm (2-96), specimen size was 37.5mm (16-100). Circumference of ESD (degree): less than 90/ 90-179/ 180-269/ 270-359/ 360 were 36/ 51/ 5/ 25/ 7, respectively. Invasion depth EP/ LPM/ MM/ SM1/ SM2 were 29/ 67/ 16/ 5/ 7, respectively.
AB578 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
How to use clip with line technique. A clip with line placed at the oral edge of specimen after circumferential mucosal incision. And, if the operator couldn’t get good traction. An additional clip with line was placed. We divided the patients into single and multiple clip groups, and tumor size, resected size, circumference of esophagus, location, the speed of ESD, En bloc resection and R0 resection rate were investigated. Result: 1. The number of single and multiple clip groups were 107 and 17 lesions, respectively. 2. The tumor size in both groups were 16mm (2-70) and 40mm (15-96) p＜0.0001. 3. The resected size in both groups were 34mm(16-83) and 59mm(34-100), p＜ 0.0001. 4. The mean circumference of ESD ulcer were 180 (60-360) and 330 degree (90-360), p＜0.0001 5. A circumferential ESD was performed for 7 patients. And, multiple clips were used for 6 of 7 patients. (p＜0.0001) 6. Dissection speed was defined as area (mm2)/duration (minutes). That of single and multiple groups were 211mm2/min (58-629) and 130mm2/min (30-387). PZ0.031 7. En bloc resection and R0 resection rate of both groups were 100%. 8. Complications: there were no severe complications including perforation. Conclusion: Multiple clips with line method was used for bigger ESD. The speed of dissection in multiple clips group was slower, but the complications and R0 resection rate was same. Therefore, multiple clips with line method was seems to be useful for big and difficult esophageal ESD. Ref １) T. Oyama, et at. Hooking knife method with intra-gastric lesion liftin method, Stomach and intest. 1155-61, 2002 ２) Tsuneo Oyama, Counter Traction Makes Endoscopic Submucosal Dissection Easier. Clin Endosc 2012;45:375-378.
Tu1199 Per-Oral Endoscopic Myotomy: A Series of 1200 Patients Yuichiro Ikebuchi*, Tetsuya Tatsuta, Kazuya Sumi, Masaki Ominami, Haruo Ikeda, Manabu Onimaru, Kenichi Goda, Hiroaki Ito, Haruhiro Inoue Showa University Koto-Toyosu Hospital, Tokyo, Japan Background: After the first case of per-oral endoscopic myotomy (POEM) at our institution in 2008, the procedure was quickly accepted as an alternative to surgical myotomy and is now established as an excellent treatment option for achalasia. This study aimed to evaluate the efficacy and safety of POEM at our University hospitals. Study Design: POEM was performed on 1200 consecutive achalasia patients at our institution between September 2008 and July 2016. A review of prospectively collected data was conducted, including procedure time, location and length of myotomy, adverse events, and patient data at 2 months 1 year after POEM. Results: Median age was 50.0 years old (range, 3-89). 552 (46%) patients were male. Of these, 469 patients (39.0%) had received previous treatment for achalasia before POEM (377 patients endoscopic balloon dilation, 40 surgery including Heller myotomy, 39 POEM, and others). Mean myotomy length was 13.5 cm (3-25.5 cm). Clinical success (Eckardt score 3) was achieved in 95% of patients after the procedure. The mean preoperative and postoperative (after 2 months) integrated relaxation pressure values were 28.9 15.3 and 13.8 6.2 mmHg. Furthermore, the Eckardt score decreased from 6.0 2.2 preoperatively to 1.2 1.2, and 1.5 1.3 within 2 months and 1 year of treatment, respectively. 34 patients (2.8%) had severe procedural-related adverse events: 14 defects of the mucosa overlying the tunnel, 10 submucosal tunnel hematoma, 2 pneumothorax, 3 pleural effusion, 2 pneumonia, 1 case of mainly prolonged intra-procedural bleeding ( > 15 min hemostasis), and 1 aspiration. 1 patient was aborted. Reasons for abortion were excessive submucosal fibrosis preventing submucosal tunneling. Adverse events over Grade IIIb by the Clavien-Dindo classification were not encountered. Conclusions: Our large series suggested POEM was a safe and effective treatment for achalasia, and will support POEM as one of the first-line achalasia therapies.
Tu1200 Survey of Current Practice Patterns for Per Oral Endoscopic Myotomy (POEM) David Lin*1, Stephen Kim1, Rabindra R. Watson1, V. Raman Muthusamy1, Mouen A. Khashab3, Gregory G. Ginsberg2, Alireza Sedarat1 1 UCLA Medical Center, Los Angeles, CA; 2University of Pennsylvania Health Systems, Philadelphia, PA; 3The Johns Hopkins Hospital, Baltimore, MD Background: Per oral endoscopic myotomy (POEM) has been shown to be safe and effective for achalasia and other spastic disorders of the esophagus. Despite rapid advancement and adoption, there has been limited data on practice patterns to guide providers. Aims: To perform an updated global assessment of POEM practice patterns to evaluate evolution of practice. Methods: Survey participants were identified as authorities in the field based on previous publications, clinical experience, and personal communication. An anonymous online survey consisting of 33 questions regarding multiple aspects of POEM, including operator background, patient
www.giejournal.org
Abstracts
selection, procedure technique, and periprocedural management was created and distributed electronically to participants. The results were analyzed using descriptive statistics. Results: Of the 78 POEM operators who were invited to participate, 28 physicians from 12 countries completed the survey (response rate of 36%). Slightly more than half (61%) were gastroenterologists; 54% operate in a GI lab setting. About half of operators had dedicated animal lab training, but overall there was variability in training. Twelve operators (43%) performed over 100 cases. Only two respondents did not operate for non-achalasia conditions. For spastic disorders not involving the lower esophageal sphincter (LES), only half of operators perform standard LES myotomy and cardiomyotomy. Almost all operators (94%) perform POEM for sigmoid esophagus and a majority (71%) did not view presence of a diverticulum as an absolute contraindication. Candida esophagitis was considered a contraindication to POEM for 43%, and most (79%) providers did not use routine antifungal prophylaxis. In the absence of prior intervention, approximately twothirds of providers preferred the anterior or anterolateral approach. In patients with esophageal body spasm, the proximal extent of myotomy was predetermined using manometry in 57%. Adequate myotomy extension beyond the LES was ensured using luminal visualization of submucosal tunnel injection agent in 46%, followed by anatomic landmarks (18%) and dual scope illumination (18%). Most utilized routine postoperative esophagram, but a significant minority (21%) did not routinely employ postoperative imaging. PPI therapy was prescribed in the vast majority of patients (82%) on discharge, but only half of operators employ routine pH testing at follow-up. Conclusions: Amongst POEM operators, there is notably a lack of uniformity in training, determination of myotomy adequacy, and pre- and postoperative care. Sigmoid esophagus, diverticulum, and non-achalasia diagnosis were generally not considered contraindications. In the absence of high quality evidence, the results from this extensive, international survey can guide current physicians and identify areas of further study to evaluate optimal practices.
Selected Survey Responses- Pre Procedure Response (%), nZ28 Cases 10-25 25-50 50-100 100-200 200-500 >500 POEM Training Dedicated institutional animal lab Live supervised cases in training Institution Sponsored course Industry sponsored course ASGE sponsored course Other Non-achalasia conditions treated with POEM EGJ outflow obstruction Jackhammer esophagus Diffuse esophageal spasm None of the above POEM in esophageal diverticulum Always Yes, depending on diverticulum size Yes, depending on diverticulum location Never POEM in esophageal candidiasis Always Yes, unless severe candidiasis Yes, unless mucosotomy site is involved Never
7% 25% 25% 21% 18% 4% 50% 25% 21% 4% 7% 25% 71% 64% 64% 7% 11% 25% 36% 29% 11% 32% 14% 43%
Selected Survey Responses- Intra and Post Procedure Response (%), nZ28 Preferred knife Triangular tip T hybrid Other Preferred cap Straight cap Oblique cap Tapered cap Cautery setting for mucosal incision Endocut Dry cut Other
www.giejournal.org
68% 18% 14% 46% 32% 21% 86% 11% 4%
Cautery setting for submucosal tunnel creation Spray coagulation Endocut Forced or swift coagulation Cautery setting for myotomy Endocut Spray coagulation Other Technique to ensure adequate myotomy extension beyond the LES Submucosal tunnel injection agent Dual scope illumination Anatomic landmarks EndoFLIP Scope insertion measurement Other Needle decompression Never 1/10 of cases or fewer 1/4 of cases or fewer 1/3 of cases or fewer Routine antibiotic lavage Esophageal lumen pre-mucosotomy Submucosal tunnel pre-myotomy Submucosal tunnel post-myotomy None Prophylactic antibiotics on discharge Penicillin (including Augmentin) Cephalosporin Fluoroquinolone Other None Routine postoperative day 1 imaging Esophagram CXR None Routine post procedure testing in asymptomatic patients Esophagram Manometry Both None Average hospital stay Same day discharge 1 night 2 nights Greater than 2 nights
64% 25% 11% 50% 46% 4%
46% 18% 18% 4% 7% 7% 19% 67% 11% 4% 7% 4% 36% 54% 25% 21% 4% 4% 46% 71% 14% 21% 14% 36% 29% 21% 4% 50% 25% 21%
Tu1201 Performance of Fully Covered and Partially Covered Self Expanding Metal Stents (Sems) for Palliation of Malignant Esophageal Obstruction. Koushik K. Das*1, Sherif Elhanafi2, Gregory G. Ginsberg2, Michael L. Kochman2, Nuzhat A. Ahmad2, Michael Rajala2, Vinay Chandrasekhara2 1 Division of Gastroenterology, Department of Medicine, Washington University, Saint Louis, MO; 2Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA Background: While the placement of SEMS for palliation of malignant esophageal obstruction has been well established as safe and effective, there continues to be controversy surrounding nutritional outcomes of patients who receive palliative stent placement. In addition, the effect of partially covered (pc) vs fully covered (fc) SEMS on the rates of stent migration and epithelial hyperplasia that occur with endoprosthetic placement remain unclear. Aim: To examine the outcomes and factors predicting adverse outcomes of patients who underwent palliative esophageal SEMS placement for malignant esophageal obstruction at a single tertiary referral center. Methods: Examination of the electronic medical record yielded 247 patients who underwent esophageal stent placement between 2007 and 2016. A total of 69 unique patients underwent SEMS placement for malignant esophageal obstruction in this time frame. All patients received either Boston Scientific Wallflextm or Ultraflextm esophageal stents. Retrospective chart review, nutrition evaluation with serial weights and albumin were noted, and univariate and multivariate regression were performed. Results: The study cohort consisted of 69 patients,
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB579
Females had shorter length of BE (p< .001); and females were less likely to have dysplastic BE (p< .001). After RTBWE, females were less likely to be hospitalized (p < .02); no differences in GI bleeding or perforation rates (P>.05), or overall complications were noted (P>.5); females were almost twice as likely to develop strictures (Odds Ratio 1.7), after considering baseline level of dysplasia, race, length of BE segment, EMR treatment before RFA, age, PPI compliance, and the number of total RFA treatment sessions. In gender efficacy analysis, fewer RFA sessions were required for females to achieve complete remission of intestinal metaplasia (CRIM)(p< .001) on univariate analysis; females had a higher CRIM rate compared to males, but statistical significance was lost on multivariate analysis; no difference was found in recurrence after CRIM (P > .05); female BE patients took longer time to achieve remission after RTBWE (P < .05) when compared with males of similar age and BE length. Conclusions and Implications of Key Findings: Although this study supports the probable association between differential outcomes of BE responses to RTBWE and female gender, there is insufficient evidence to conclude this variations of gender influences. Our data call for larger examination of facilitators and barriers to sustain BE remission strategies in women.
Tu1197 Strategies for Stenosis After ESD for Early Esophageal Cancer in Our Hospital Yoshiaki Takahashi*, Shinpei Kawaguchi, Haruhiko Ozaki, Yosuke Inoue, Kazuhiro Ota, Satoshi Harada, Yuichi Kojima, Toshihisa Takeuchi, Kazuhide Higuchi Osaka Medical College, Takatsuki, Japan Background and Purpose: Currently, the usefulness of oral steroids and topical steroid injection for the prevention of stenosis after endoscopic submucosal dissection (ESD) of the esophagus is being examined. However, there have been many patients with stenosis despite its prevention; endoscopic balloon dilatation (EBD) is performed. We investigated the current status of post-ESD stenosis in our hospital and usefulness of stenting in non-responders to EBD. Methods: The subjects were 165 patients with early esophageal cancer who underwent ESD in our hospital between July 2009 and December 2015. Based on endoscopy findings the day after ESD, the extent of the post-ESD ulcer as a percentage of the esophageal circumference was classified into 4 grades: (1) <50%, (2) 50-74%, (3) 75-99%, and (4) 100%. It was examined with respect to the site, prevention methods, and presence or absence of stenosis. Furthermore, we reviewed additional treatment for non-responders to EBD. Results: Of 110 patients with post-ESD ulcers occupying <50% of the esophageal circumference, there was no stenosis in any patient. Of 32 patients with postESD ulcers occupying 50-74%, stenosis was present in 1, whereas it was absent in 31 (stenosis rate: 3%). Of 18 patients with post-ESD ulcers occupying 75-99%, stenosis was present in 10, whereas it was absent in 8 (stenosis rate: 55.5%). Of 5 patients with post-ESD ulcers occupying 100%, stenosis was present in 2, whereas it was absent in 3 (stenosis rate: 40%). For 15 patients with post-ESD ulcers occupying 7599%, topical steroid injection had been performed to prevent stenosis, but its preventive effects were not marked (stenosis was present in 9, whereas it was absent in 6, with a response rate of 40%). To 4 patients with post-ESD ulcers occupying 100%, oral steroids had been administered for prevention. Stenosis was present in 1, whereas it was absent in 3, with a response rate of 75%. Oral steroids were effective. For patients with stenosis, EBD was performed. In 10 of the 13 patients, an improvement was achieved, but stenosis treatment was difficult in the other 3 patients. For these patients, stenting was performed, followed by stent removal after 2 months. The results were evaluated. In 2 patients, an improvement in stenosis was achieved, whereas the stent was ineffective due to frequent migration in 1, requiring periodic EBD. Conclusion: In our hospital, oral steroids were more useful than topical steroid injection for preventing stenosis. Furthermore, stenting for non-responders may be useful.
Tu1198 Efficacy of Multiple Clips With Line Method for Endoscopic Submucosal Dissection of Esophageal Cancer Nobukazu Yorimitsu*, Tsuneo Oyama, Akiko Takahashi Saku Central Hospital Advanced Care Center, Saku city, Japan Background: Clip with line method was developed in 2002 by our institute, and widely accepted technique that make ESD easier1,2. However, sometimes single clip with line is not effective, when the size of target lesion was big. Aim: The aim of this retrospective study is to clarify the usefulness of multiple clips with line method for esophageal ESD. Patients and methods: A consecutive one hundred twenty four esophageal ESD from March 2014 to August 2016 treated by clip with line method were enrolled to this retrospective study. Patients characteristics, Male 112, Female12, Mean age 69 (30-91), Location Ce:6, Ut: 7, Mt:89, Lt:19, Ae:3. Macroscopic type 0-I : 3, IIa : 7, IIb : 42 and IIc : 72, Tumor size was 20.5mm (2-96), specimen size was 37.5mm (16-100). Circumference of ESD (degree): less than 90/ 90-179/ 180-269/ 270-359/ 360 were 36/ 51/ 5/ 25/ 7, respectively. Invasion depth EP/ LPM/ MM/ SM1/ SM2 were 29/ 67/ 16/ 5/ 7, respectively.
AB578 GASTROINTESTINAL ENDOSCOPY Volume 85, No. 5S : 2017
How to use clip with line technique. A clip with line placed at the oral edge of specimen after circumferential mucosal incision. And, if the operator couldn’t get good traction. An additional clip with line was placed. We divided the patients into single and multiple clip groups, and tumor size, resected size, circumference of esophagus, location, the speed of ESD, En bloc resection and R0 resection rate were investigated. Result: 1. The number of single and multiple clip groups were 107 and 17 lesions, respectively. 2. The tumor size in both groups were 16mm (2-70) and 40mm (15-96) p＜0.0001. 3. The resected size in both groups were 34mm(16-83) and 59mm(34-100), p＜ 0.0001. 4. The mean circumference of ESD ulcer were 180 (60-360) and 330 degree (90-360), p＜0.0001 5. A circumferential ESD was performed for 7 patients. And, multiple clips were used for 6 of 7 patients. (p＜0.0001) 6. Dissection speed was defined as area (mm2)/duration (minutes). That of single and multiple groups were 211mm2/min (58-629) and 130mm2/min (30-387). PZ0.031 7. En bloc resection and R0 resection rate of both groups were 100%. 8. Complications: there were no severe complications including perforation. Conclusion: Multiple clips with line method was used for bigger ESD. The speed of dissection in multiple clips group was slower, but the complications and R0 resection rate was same. Therefore, multiple clips with line method was seems to be useful for big and difficult esophageal ESD. Ref １) T. Oyama, et at. Hooking knife method with intra-gastric lesion liftin method, Stomach and intest. 1155-61, 2002 ２) Tsuneo Oyama, Counter Traction Makes Endoscopic Submucosal Dissection Easier. Clin Endosc 2012;45:375-378.
Tu1199 Per-Oral Endoscopic Myotomy: A Series of 1200 Patients Yuichiro Ikebuchi*, Tetsuya Tatsuta, Kazuya Sumi, Masaki Ominami, Haruo Ikeda, Manabu Onimaru, Kenichi Goda, Hiroaki Ito, Haruhiro Inoue Showa University Koto-Toyosu Hospital, Tokyo, Japan Background: After the first case of per-oral endoscopic myotomy (POEM) at our institution in 2008, the procedure was quickly accepted as an alternative to surgical myotomy and is now established as an excellent treatment option for achalasia. This study aimed to evaluate the efficacy and safety of POEM at our University hospitals. Study Design: POEM was performed on 1200 consecutive achalasia patients at our institution between September 2008 and July 2016. A review of prospectively collected data was conducted, including procedure time, location and length of myotomy, adverse events, and patient data at 2 months 1 year after POEM. Results: Median age was 50.0 years old (range, 3-89). 552 (46%) patients were male. Of these, 469 patients (39.0%) had received previous treatment for achalasia before POEM (377 patients endoscopic balloon dilation, 40 surgery including Heller myotomy, 39 POEM, and others). Mean myotomy length was 13.5 cm (3-25.5 cm). Clinical success (Eckardt score 3) was achieved in 95% of patients after the procedure. The mean preoperative and postoperative (after 2 months) integrated relaxation pressure values were 28.9 15.3 and 13.8 6.2 mmHg. Furthermore, the Eckardt score decreased from 6.0 2.2 preoperatively to 1.2 1.2, and 1.5 1.3 within 2 months and 1 year of treatment, respectively. 34 patients (2.8%) had severe procedural-related adverse events: 14 defects of the mucosa overlying the tunnel, 10 submucosal tunnel hematoma, 2 pneumothorax, 3 pleural effusion, 2 pneumonia, 1 case of mainly prolonged intra-procedural bleeding ( > 15 min hemostasis), and 1 aspiration. 1 patient was aborted. Reasons for abortion were excessive submucosal fibrosis preventing submucosal tunneling. Adverse events over Grade IIIb by the Clavien-Dindo classification were not encountered. Conclusions: Our large series suggested POEM was a safe and effective treatment for achalasia, and will support POEM as one of the first-line achalasia therapies.
Tu1200 Survey of Current Practice Patterns for Per Oral Endoscopic Myotomy (POEM) David Lin*1, Stephen Kim1, Rabindra R. Watson1, V. Raman Muthusamy1, Mouen A. Khashab3, Gregory G. Ginsberg2, Alireza Sedarat1 1 UCLA Medical Center, Los Angeles, CA; 2University of Pennsylvania Health Systems, Philadelphia, PA; 3The Johns Hopkins Hospital, Baltimore, MD Background: Per oral endoscopic myotomy (POEM) has been shown to be safe and effective for achalasia and other spastic disorders of the esophagus. Despite rapid advancement and adoption, there has been limited data on practice patterns to guide providers. Aims: To perform an updated global assessment of POEM practice patterns to evaluate evolution of practice. Methods: Survey participants were identified as authorities in the field based on previous publications, clinical experience, and personal communication. An anonymous online survey consisting of 33 questions regarding multiple aspects of POEM, including operator background, patient
www.giejournal.org
Abstracts
selection, procedure technique, and periprocedural management was created and distributed electronically to participants. The results were analyzed using descriptive statistics. Results: Of the 78 POEM operators who were invited to participate, 28 physicians from 12 countries completed the survey (response rate of 36%). Slightly more than half (61%) were gastroenterologists; 54% operate in a GI lab setting. About half of operators had dedicated animal lab training, but overall there was variability in training. Twelve operators (43%) performed over 100 cases. Only two respondents did not operate for non-achalasia conditions. For spastic disorders not involving the lower esophageal sphincter (LES), only half of operators perform standard LES myotomy and cardiomyotomy. Almost all operators (94%) perform POEM for sigmoid esophagus and a majority (71%) did not view presence of a diverticulum as an absolute contraindication. Candida esophagitis was considered a contraindication to POEM for 43%, and most (79%) providers did not use routine antifungal prophylaxis. In the absence of prior intervention, approximately twothirds of providers preferred the anterior or anterolateral approach. In patients with esophageal body spasm, the proximal extent of myotomy was predetermined using manometry in 57%. Adequate myotomy extension beyond the LES was ensured using luminal visualization of submucosal tunnel injection agent in 46%, followed by anatomic landmarks (18%) and dual scope illumination (18%). Most utilized routine postoperative esophagram, but a significant minority (21%) did not routinely employ postoperative imaging. PPI therapy was prescribed in the vast majority of patients (82%) on discharge, but only half of operators employ routine pH testing at follow-up. Conclusions: Amongst POEM operators, there is notably a lack of uniformity in training, determination of myotomy adequacy, and pre- and postoperative care. Sigmoid esophagus, diverticulum, and non-achalasia diagnosis were generally not considered contraindications. In the absence of high quality evidence, the results from this extensive, international survey can guide current physicians and identify areas of further study to evaluate optimal practices.
Selected Survey Responses- Pre Procedure Response (%), nZ28 Cases 10-25 25-50 50-100 100-200 200-500 >500 POEM Training Dedicated institutional animal lab Live supervised cases in training Institution Sponsored course Industry sponsored course ASGE sponsored course Other Non-achalasia conditions treated with POEM EGJ outflow obstruction Jackhammer esophagus Diffuse esophageal spasm None of the above POEM in esophageal diverticulum Always Yes, depending on diverticulum size Yes, depending on diverticulum location Never POEM in esophageal candidiasis Always Yes, unless severe candidiasis Yes, unless mucosotomy site is involved Never
7% 25% 25% 21% 18% 4% 50% 25% 21% 4% 7% 25% 71% 64% 64% 7% 11% 25% 36% 29% 11% 32% 14% 43%
Selected Survey Responses- Intra and Post Procedure Response (%), nZ28 Preferred knife Triangular tip T hybrid Other Preferred cap Straight cap Oblique cap Tapered cap Cautery setting for mucosal incision Endocut Dry cut Other
www.giejournal.org
68% 18% 14% 46% 32% 21% 86% 11% 4%
Cautery setting for submucosal tunnel creation Spray coagulation Endocut Forced or swift coagulation Cautery setting for myotomy Endocut Spray coagulation Other Technique to ensure adequate myotomy extension beyond the LES Submucosal tunnel injection agent Dual scope illumination Anatomic landmarks EndoFLIP Scope insertion measurement Other Needle decompression Never 1/10 of cases or fewer 1/4 of cases or fewer 1/3 of cases or fewer Routine antibiotic lavage Esophageal lumen pre-mucosotomy Submucosal tunnel pre-myotomy Submucosal tunnel post-myotomy None Prophylactic antibiotics on discharge Penicillin (including Augmentin) Cephalosporin Fluoroquinolone Other None Routine postoperative day 1 imaging Esophagram CXR None Routine post procedure testing in asymptomatic patients Esophagram Manometry Both None Average hospital stay Same day discharge 1 night 2 nights Greater than 2 nights
64% 25% 11% 50% 46% 4%
46% 18% 18% 4% 7% 7% 19% 67% 11% 4% 7% 4% 36% 54% 25% 21% 4% 4% 46% 71% 14% 21% 14% 36% 29% 21% 4% 50% 25% 21%
Tu1201 Performance of Fully Covered and Partially Covered Self Expanding Metal Stents (Sems) for Palliation of Malignant Esophageal Obstruction. Koushik K. Das*1, Sherif Elhanafi2, Gregory G. Ginsberg2, Michael L. Kochman2, Nuzhat A. Ahmad2, Michael Rajala2, Vinay Chandrasekhara2 1 Division of Gastroenterology, Department of Medicine, Washington University, Saint Louis, MO; 2Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA Background: While the placement of SEMS for palliation of malignant esophageal obstruction has been well established as safe and effective, there continues to be controversy surrounding nutritional outcomes of patients who receive palliative stent placement. In addition, the effect of partially covered (pc) vs fully covered (fc) SEMS on the rates of stent migration and epithelial hyperplasia that occur with endoprosthetic placement remain unclear. Aim: To examine the outcomes and factors predicting adverse outcomes of patients who underwent palliative esophageal SEMS placement for malignant esophageal obstruction at a single tertiary referral center. Methods: Examination of the electronic medical record yielded 247 patients who underwent esophageal stent placement between 2007 and 2016. A total of 69 unique patients underwent SEMS placement for malignant esophageal obstruction in this time frame. All patients received either Boston Scientific Wallflextm or Ultraflextm esophageal stents. Retrospective chart review, nutrition evaluation with serial weights and albumin were noted, and univariate and multivariate regression were performed. Results: The study cohort consisted of 69 patients,
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB579