- Email: [email protected]
Tu1207 Normative Esophageal Pressure Topography Metrics for Data Derived From the Sandhill High Resolution Manometry Assembly
AGA Abstracts
higher with 5 ml swallows, which is consistent with less complete relaxations of LES. DCI was not significantly affected by different volumes in the same posture; however, the DCI of 5ml volume swallows was higher in the supine position than the upright position. The bolus transit time as presented by CFV was faster with 5 ml swallows and upright position (Table). Conclusions: Larger volume swallows initiated more complete LES and UES relaxation along with less intrabolus pressure. These findings suggest larger volume swallows may increase sensitivity of finding true gastroesophageal junction (GEJ) obstructions such as achalasia, pseudoachalasia, GEJ outflow obstruction, and UES dysmotility. In addition, using a larger volume may decrease false positives of abnormal relaxation and hypotensive or failed peristalsis secondary to inadequate volume.
UES: Upper Esophageal Sphincter LES: Lower Esophageal Sphincter DCI: Distal Contractile Interval IBT: Impaired Bolus Transfer IBC: Impaired Bolus Clearance
Tu1206 Dysphagia and Oculopharyngeal Muscular Dysptrophy: More Than an Oropharyngeal Problem? Leslie Price, Martin G. Kistin, Michael D. Gilles, Thomas Y. Ma Background: Oculopharyngeal muscular dystrophy (OPMD) is a rare autosomal dominant progressive muscular disorder characterized by ptosis, dysphonia, dysphagia, and proximal limb weakness. Patients with dysphagia report increased time to eat meals, avoidance of dry foods, and regurgitation of food. Treatment of dysphagia has targeted the cricopharyngeus muscle via dilation, myotomy, or botox. Studies with conventional solid state and perfusion manometry have demonstrated abnormalities of esophageal peristalsis. Scintigraphy studies have shown impaired pharyngeal bolus transfer to the esophagus and impaired esophageal bolus clearance to the stomach. This study used high-resolution esophageal manometry with impedance to examine the esophageal abnormalities in symptomatic and asymptomatic patients with OPMD. Methods: Between 2011-2012, 8 patients were enrolled from the Gastroenterology or Neurology OPMD clinic at the University of New Mexico Hospital. OPMD was confirmed by genetic analysis or clinical diagnosis. Patients diagnosed clinically had progressive ptosis and/or dysphagia and positive family history. Patients underwent highresolution esophageal manometry with impedance. All patients completed a questionnaire regarding onset and severity of symptoms, prior medical therapy, and family history. Results: Dysphagia was present in 88% (7/8) of patients. Impedance was abnormal in all patients with dysphagia with decreased bolus transfer from the pharynx to the esophagus (100%; 7/7). Nearly all patients had decreased bolus clearance from the esophagus to the stomach (86%; 6/7). Eighty-six percent (6/7) had manometric abnormalities of the upper esophageal sphincter and 57% (4/7) of this group had decreased pressures in the proximal esophagus below 30 mm Hg. Other findings included distal esophageal pressure . 200 mm Hg (4/ 7), multiple double peaked waves (2/7), and simultaneous contractions (1/7). These findings were minor and infrequent, and only one patient met criteria for severe distal esophageal peristaltic dysfunction using current classification. Conclusion: This is the first study to show impedance abnormalities with impaired esophageal bolus clearance and pharyngeal bolus transfer in all patients with dysphagia and OPMD. This suggests that OPMD affects esophageal smooth muscle in addition to oropharyngeal skeletal muscle. Using current classification, nearly all patients had normal esophageal manometry, indicating that impedance may be a more sensitive measure of abnormalities in this group of patients. This may have implications for future evaluation of treatment modalities. OPMD Patient Demographics, High Resolution Esophageal Manometry & Impedance Results
Left: High resolution esophageal manometry with proximal and distal esophageal break in 30 mm Hg isobar contour. Right: Impedance showing impaired pharyngeal bolus transfer and impaired esophageal clearance to the stomach. Tu1207 Normative Esophageal Pressure Topography Metrics for Data Derived From the Sandhill High Resolution Manometry Assembly Gardenia Carmo, Gustavo A. Mota, Ricardo B. Oliveira Background and aims: High Resolution Manometry with Esophageal Pressure Topography (HRM), overcomes several limitations of the conventional manometry by utilizing enhanced spatial pressure resolution and data visualization. Normal values of HRM-specific metrics have been published only for the Given Imaging HRM system, and it is not certain that these normative data necessarily apply to data from other manufacturers' devices (Kahrilas PJ, Peters JH. Neurogastrenterol Motil 2012; 24(suppl 1): 11-19). We aimed at establishing normative ranges and cut-off values for the HRM metrics derived from the Sandhill HRM assembly in both sitting and supine positions, and apply the upper cut-off values (95th percentiles) of Integrated Relaxation Pressure (IRP) to the data of patients with non-obstructive dysphagia. Methods: HRM studies including test swallows in both a supine and sitting position were done on 30 healthy volunteers (17 women, age: 20-55 years; median age: 36.5 years), 12 patients with idiopathic achalasia by conventional criteria, and 27 patients with dysphagia and a normal-appearing esophagus (NAE), employing the Sandhill's HRM system (InSIGHT™ HRiM®). Ten single-swallows of 5-cc saline in each position were recorded. Data were analyzed by a single investigator (GCC) employing the BioViEw® analysis software. IRP, Distal Contractile Integral (DCI), Distal Latency (DL), and Contractile Front Velocity (CFV) were calculated. Normative HRM metrics were derived from data the 30 volunteers in both supine and sitting positions. Results: Normative HRM metrics are shown in Table. The IRP, DCI, and DL were lower, whereas the CFV tended to be higher in the sitting position than in supine position. Abnormal IRP values in both positions were found in 5 of the 27 NAE patients, and only in the sitting position in another 3. Abnormally high IRP values in both positions were found in 10 of the 12 ACH patients; in 1 patient had abnormal IRP only sitting, and another one only supine. Conclusions: The upper limits of normal for the IRP and DCI from the Sandhill HRM assembly are substantially higher than those previously reported for the Given Imaging HRM assembly; HRM cut-off values are dependent on the posture in which the study is conducted; IRP generated from the Sandhill HRM assembly accurately detects impairment of esophagogastric junction relaxation; HRM metrics must be linked to the assembly with which they were derived. Normative HRM data for the 30 healthy volunteers in sitting and supine position
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AGA Abstracts
Tu1209 Analysis of 1001 Patients Submitted to Endoscopic Treatment of Excess Weight With an Intragastric Balloon Ricardo J. Fittipaldi-Fernandez, Cristina F. Diestel
AGA Abstracts
INTRODUCTION: Endoscopic methods, especially the intragastric balloon (IGB), have been shown to be effective for the treatment of excess weight. OBJECTIVE: To assess the efficacy and complications of excess weight treatment with an IGB in patients seen at the Endogastro Med Service clinic. METHODS: A total of 1001 patients were analyzed. An Allergan IGB (BIB®) with a volume of 600 to 700 ml was used. The patients had a minimum initial body mass index (BMI) of 27 kg/m2 and were followed up by a multidisciplinary team consisting of a nutritionist, a doctor and a psychologist. For statistical analysis, the patients were divided into groups according to sex and degree of excess weight (overweight and grade I, II and III obesity). Data were analyzed using descriptive statistical methods, the Student t-test, Spearman correlation, and analysis of variance followed by the Tukey post-test. The level of significance was set at p ,0.05. RESULTS: 43 patients were excluded from the analysis: 27 (2,69%) due to early IGB removal, 4 (0.39%) due to absence of weight loss, 2 (0.19%) due to weight gain, and 10 (0,99%) due to incomplete data. The incidence of fungus was 0.39% (n=4) and the incidence of leakage was 0.19% (n=2). Of the 958 remaining patients, 747 were women and 211 were men. Mean age was 37.33 years. The patients showed a significant weight loss, with a significantly lower final BMI (mean: 29.02±5.01 kg/m2; range: 19.79-47.03) than the initial BMI (mean: 36.94±5.43 kg/m2; range: 27.04-62.03) (p,0.0001). Mean BMI reduction was 7.92±2.83 kg/m2 (range: 1.70-17.09). Mean percent weight loss was 19.55±6.63% and mean percent excess weight loss was 70.88±38.56% (range: 11,35-339,03). There was no difference between BMI ranges regarding percent initial weight loss (p=0.5143) and there was no difference between men and women regarding BMI reduction (p=0.0944) or percent initial weight loss (p=0.8013). There was a positive correlation between the numbers of visits to a nutritionist and a greater loss of initial weight (p=0.0001). CONCLUSION: Endoscopic treatment of excess weight with an IGB has been established as an excellent therapeutic option for patients of both genders with overweight or different degrees of obesity. Tu1210 Obesity and Swallowable Intragastric Balloon: A European Pilot Study Francois Mion, Mostafa Ibrahim, Sophie Marjoux, Sonia Dugardeyn, Sabine Roman, Thierry Ponchon, Jacques M. Deviere
HRM, high resolution manometry; IQR, interquartile range.; LOS Lower oesophageal sphincter
Objectives Intragastric balloons allow transient weight loss in obese and overweight patients. The introduction in the stomach and their withdrawal involve iterative endoscopic procedures, usually under sedation or general anesthesia. We investigated the safety and efficacy of a new swallowable intragastric balloon (Obalon®) which can be placed without upper GI endoscopy and allows titration during the treatment period. Methods From January 2012 to April 2012, 17 patients (15 women, 39±9 years, BMI: 31±3 kg/m2) have been included in Brussels and Lyon. Ingestion of the balloon (inserted in a soluble capsule 30 x 15 mm, and connected to a detachable inflation-catheter of 2 Fr in diameter) was performed under fluoroscopic control, and the balloon inflated with 250 cc of gas once in place in the stomach. An additional balloon could be administered at 4 and 8 weeks depending on the tolerance and weight loss. Patients were under PPIs for the duration of the study. The balloons were endoscopically removed under sedation at 12 weeks. Results A balloon could be inserted in all patients; a second balloon was ingested by 16 patients (inability to swallow in 1) between 4 and 5 weeks after the first, and a 3rd balloon ingested between 7 and 9 weeks by 10 patients (no failures of ingestion). The mean time to insert the balloon (ingestion+ inflation) was 8 min (extreme: 4-18). No unexpected or serious adverse events occurred. Epigastric pain/cramping was the most common adverse event occurring in 12 (71%) subjects, 6 resolved without medical therapy, 6 with oral medical therapy and none required hospitalization. Nausea was also reported in 7 (41%) subjects. The endoscopic withdrawal of the balloons was done under sedation without tracheal intubation: the mean duration of the procedure was 14±6 minutes (range: 6-24 min). At the time of withdrawal, no balloon was spontaneously deflated, and no ulcerations were observed with the exception of 1 mild case, possibly unrelated to the device, in a subject who used NSAIDs. Weight loss compared to baseline was statistically significant (p , 0.0001) with a reduction (mean±SD) of 2.2±1.7 kg, 4.0±2.6 kg, 5.8±2.9 kg at 4, 8 and 12 weeks, respectively. Percent Excess Weight Loss was 15.7± 12.7%, 28.1±18.1%, 44.1±29.4% at 4, 8 and 12 weeks, respectively. Conclusions The data from this study demonstrate this new swallowable intragastric balloon to be safe and easy to administrate, well-tolerated and effective in terms of weight loss over a 12 week period.
Tu1208 Provocative Manometry With Postprandial Monitoring Enhances Diagnostic Yield in Patients With Intermittent Symptoms Victor Chedid, Sameer Dhalla, Monica Nandwani, Bani Chander Roland, John O. Clarke, Ellen M. Stein Background: High-resolution esophageal manometry (HREM) is the gold standard for evaluation of esophageal motility disorders. However, symptoms rarely occur during a monitored liquid swallow, especially when symptoms are intermittent. Recent literature supports use of provocative HREM protocols to more reliably induce symptoms and assess motility when "under duress." Our protocol involves patients bringing a meal to be eaten while undergoing prolonged monitoring during and after meal ingestion. We hypothesized that this would provoke symptoms and increase diagnostic yield. Aims: The aims of our study were to determine whether 1) the addition of dedicated postprandial monitoring enhanced diagnostic yield in patients with intermittent symptoms, and whether 2) a 30-minute postprandial monitoring period was sufficient to capture symptoms in the majority of referred patients. Methods: Consecutive patients who underwent HREM with postprandial monitoring at a single academic referral center from January to October 2012 were reviewed. Demographics, initial diagnosis, final diagnosis, number of symptoms, and changes in management were recorded. Patients were encouraged to bring a meal of their choice which would be likely to produce symptoms. All patients underwent standard HREM with 10 liquid swallows. The meal was then ingested while the HREM catheter remained in position for 30 minutes. All symptoms were noted. Results: Out of 458 patients who underwent HREM during the study period, 15 patients (mean age= 52.9, range= 25-80, Females=66.7%) were referred specifically for HREM with extended postprandial monitoring. Indications were: refractory belching (6), atypical GERD (3), regurgitation (3), and intermittent dysphagia (3). Ten of the 15 patients recorded symptoms (belching, dysphagia or chest pressure) during the 30 minute monitoring period. The number of symptoms provoked ranged from 0 to "innumerable" with a median value of 5. Six of the 15 patients had new manometric findings after meal ingestion, that were not evident when taking only liquid swallows, with subsequent changes in both diagnoses and management. New diagnoses detected with dedicated postprandial monitoring included rumination, supragastric belching, gastric belching, and diffuse esophageal spasm. Conclusion: HREM with extended postprandial monitoring enhanced diagnostic yield as compared to conventional HREM. Postprandial monitoring should be considered in patients with intermittent symptoms such as dysphagia or belching, where symptomatic provocation is desired to assure complete evaluation, or in patients for whom rumination is suspected. Thirty minutes appears to be an adequate duration to allow symptom genesis. Prospective evaluation will help determine which subset of symptoms has highest diagnostic yield with this protocol.
AGA Abstracts
Tu1211 Endoscopic Treatment of Post Laparoscopic Sleeve Gastrectomy Fistula : Results From a Multicenter Retrospective Study Dimitri Christophorou, Natalie Funakoshi, Jean-Christophe Valats, Bruno Vedrenne, Frederic Prat, Philippe Bulois, Vincent Maunoury, Sebastien Decoster, Emmanuel Coron, Claire Duflos, Marie-Christine Picot, David Nocca, Paul Bauret, Pierre Blanc Introduction Laparoscopic Sleeve Gastrectomy (LSG) is the most frequently performed bariatric surgery procedure in France. Staple line leak is the main complication, for which healing is difficult to obtain. Aims: To evaluate the effectiveness of endoscopic treatment in the repair of staple line leaks, to describe the various endoscopic techniques used, to identify the predictive factors of healing following endoscopic management. Methods Patients with LSG staple line leaks were included in a multicenter retrospective cohort. Data was collected on therapeutic procedures performed (endoscopic or surgical), treatment complications and time to healing (spontaneous, or following endoscopic or surgical treatment). Predictive factors of healing after endoscopic treatment were evaluated in univariate analysis by a Logrank test, then in a multivariate analysis using a Cox model. The protocol was approved by the research and development committee of the French Digestive Endoscopy Society. Results 104 patients with leaks (83% females, mean age 39.6 years, mean BMI 44.3 kg/m2)
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higher with 5 ml swallows, which is consistent with less complete relaxations of LES. DCI was not significantly affected by different volumes in the same posture; however, the DCI of 5ml volume swallows was higher in the supine position than the upright position. The bolus transit time as presented by CFV was faster with 5 ml swallows and upright position (Table). Conclusions: Larger volume swallows initiated more complete LES and UES relaxation along with less intrabolus pressure. These findings suggest larger volume swallows may increase sensitivity of finding true gastroesophageal junction (GEJ) obstructions such as achalasia, pseudoachalasia, GEJ outflow obstruction, and UES dysmotility. In addition, using a larger volume may decrease false positives of abnormal relaxation and hypotensive or failed peristalsis secondary to inadequate volume.
UES: Upper Esophageal Sphincter LES: Lower Esophageal Sphincter DCI: Distal Contractile Interval IBT: Impaired Bolus Transfer IBC: Impaired Bolus Clearance
Tu1206 Dysphagia and Oculopharyngeal Muscular Dysptrophy: More Than an Oropharyngeal Problem? Leslie Price, Martin G. Kistin, Michael D. Gilles, Thomas Y. Ma Background: Oculopharyngeal muscular dystrophy (OPMD) is a rare autosomal dominant progressive muscular disorder characterized by ptosis, dysphonia, dysphagia, and proximal limb weakness. Patients with dysphagia report increased time to eat meals, avoidance of dry foods, and regurgitation of food. Treatment of dysphagia has targeted the cricopharyngeus muscle via dilation, myotomy, or botox. Studies with conventional solid state and perfusion manometry have demonstrated abnormalities of esophageal peristalsis. Scintigraphy studies have shown impaired pharyngeal bolus transfer to the esophagus and impaired esophageal bolus clearance to the stomach. This study used high-resolution esophageal manometry with impedance to examine the esophageal abnormalities in symptomatic and asymptomatic patients with OPMD. Methods: Between 2011-2012, 8 patients were enrolled from the Gastroenterology or Neurology OPMD clinic at the University of New Mexico Hospital. OPMD was confirmed by genetic analysis or clinical diagnosis. Patients diagnosed clinically had progressive ptosis and/or dysphagia and positive family history. Patients underwent highresolution esophageal manometry with impedance. All patients completed a questionnaire regarding onset and severity of symptoms, prior medical therapy, and family history. Results: Dysphagia was present in 88% (7/8) of patients. Impedance was abnormal in all patients with dysphagia with decreased bolus transfer from the pharynx to the esophagus (100%; 7/7). Nearly all patients had decreased bolus clearance from the esophagus to the stomach (86%; 6/7). Eighty-six percent (6/7) had manometric abnormalities of the upper esophageal sphincter and 57% (4/7) of this group had decreased pressures in the proximal esophagus below 30 mm Hg. Other findings included distal esophageal pressure . 200 mm Hg (4/ 7), multiple double peaked waves (2/7), and simultaneous contractions (1/7). These findings were minor and infrequent, and only one patient met criteria for severe distal esophageal peristaltic dysfunction using current classification. Conclusion: This is the first study to show impedance abnormalities with impaired esophageal bolus clearance and pharyngeal bolus transfer in all patients with dysphagia and OPMD. This suggests that OPMD affects esophageal smooth muscle in addition to oropharyngeal skeletal muscle. Using current classification, nearly all patients had normal esophageal manometry, indicating that impedance may be a more sensitive measure of abnormalities in this group of patients. This may have implications for future evaluation of treatment modalities. OPMD Patient Demographics, High Resolution Esophageal Manometry & Impedance Results
Left: High resolution esophageal manometry with proximal and distal esophageal break in 30 mm Hg isobar contour. Right: Impedance showing impaired pharyngeal bolus transfer and impaired esophageal clearance to the stomach. Tu1207 Normative Esophageal Pressure Topography Metrics for Data Derived From the Sandhill High Resolution Manometry Assembly Gardenia Carmo, Gustavo A. Mota, Ricardo B. Oliveira Background and aims: High Resolution Manometry with Esophageal Pressure Topography (HRM), overcomes several limitations of the conventional manometry by utilizing enhanced spatial pressure resolution and data visualization. Normal values of HRM-specific metrics have been published only for the Given Imaging HRM system, and it is not certain that these normative data necessarily apply to data from other manufacturers' devices (Kahrilas PJ, Peters JH. Neurogastrenterol Motil 2012; 24(suppl 1): 11-19). We aimed at establishing normative ranges and cut-off values for the HRM metrics derived from the Sandhill HRM assembly in both sitting and supine positions, and apply the upper cut-off values (95th percentiles) of Integrated Relaxation Pressure (IRP) to the data of patients with non-obstructive dysphagia. Methods: HRM studies including test swallows in both a supine and sitting position were done on 30 healthy volunteers (17 women, age: 20-55 years; median age: 36.5 years), 12 patients with idiopathic achalasia by conventional criteria, and 27 patients with dysphagia and a normal-appearing esophagus (NAE), employing the Sandhill's HRM system (InSIGHT™ HRiM®). Ten single-swallows of 5-cc saline in each position were recorded. Data were analyzed by a single investigator (GCC) employing the BioViEw® analysis software. IRP, Distal Contractile Integral (DCI), Distal Latency (DL), and Contractile Front Velocity (CFV) were calculated. Normative HRM metrics were derived from data the 30 volunteers in both supine and sitting positions. Results: Normative HRM metrics are shown in Table. The IRP, DCI, and DL were lower, whereas the CFV tended to be higher in the sitting position than in supine position. Abnormal IRP values in both positions were found in 5 of the 27 NAE patients, and only in the sitting position in another 3. Abnormally high IRP values in both positions were found in 10 of the 12 ACH patients; in 1 patient had abnormal IRP only sitting, and another one only supine. Conclusions: The upper limits of normal for the IRP and DCI from the Sandhill HRM assembly are substantially higher than those previously reported for the Given Imaging HRM assembly; HRM cut-off values are dependent on the posture in which the study is conducted; IRP generated from the Sandhill HRM assembly accurately detects impairment of esophagogastric junction relaxation; HRM metrics must be linked to the assembly with which they were derived. Normative HRM data for the 30 healthy volunteers in sitting and supine position
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AGA Abstracts
Tu1209 Analysis of 1001 Patients Submitted to Endoscopic Treatment of Excess Weight With an Intragastric Balloon Ricardo J. Fittipaldi-Fernandez, Cristina F. Diestel
AGA Abstracts
INTRODUCTION: Endoscopic methods, especially the intragastric balloon (IGB), have been shown to be effective for the treatment of excess weight. OBJECTIVE: To assess the efficacy and complications of excess weight treatment with an IGB in patients seen at the Endogastro Med Service clinic. METHODS: A total of 1001 patients were analyzed. An Allergan IGB (BIB®) with a volume of 600 to 700 ml was used. The patients had a minimum initial body mass index (BMI) of 27 kg/m2 and were followed up by a multidisciplinary team consisting of a nutritionist, a doctor and a psychologist. For statistical analysis, the patients were divided into groups according to sex and degree of excess weight (overweight and grade I, II and III obesity). Data were analyzed using descriptive statistical methods, the Student t-test, Spearman correlation, and analysis of variance followed by the Tukey post-test. The level of significance was set at p ,0.05. RESULTS: 43 patients were excluded from the analysis: 27 (2,69%) due to early IGB removal, 4 (0.39%) due to absence of weight loss, 2 (0.19%) due to weight gain, and 10 (0,99%) due to incomplete data. The incidence of fungus was 0.39% (n=4) and the incidence of leakage was 0.19% (n=2). Of the 958 remaining patients, 747 were women and 211 were men. Mean age was 37.33 years. The patients showed a significant weight loss, with a significantly lower final BMI (mean: 29.02±5.01 kg/m2; range: 19.79-47.03) than the initial BMI (mean: 36.94±5.43 kg/m2; range: 27.04-62.03) (p,0.0001). Mean BMI reduction was 7.92±2.83 kg/m2 (range: 1.70-17.09). Mean percent weight loss was 19.55±6.63% and mean percent excess weight loss was 70.88±38.56% (range: 11,35-339,03). There was no difference between BMI ranges regarding percent initial weight loss (p=0.5143) and there was no difference between men and women regarding BMI reduction (p=0.0944) or percent initial weight loss (p=0.8013). There was a positive correlation between the numbers of visits to a nutritionist and a greater loss of initial weight (p=0.0001). CONCLUSION: Endoscopic treatment of excess weight with an IGB has been established as an excellent therapeutic option for patients of both genders with overweight or different degrees of obesity. Tu1210 Obesity and Swallowable Intragastric Balloon: A European Pilot Study Francois Mion, Mostafa Ibrahim, Sophie Marjoux, Sonia Dugardeyn, Sabine Roman, Thierry Ponchon, Jacques M. Deviere
HRM, high resolution manometry; IQR, interquartile range.; LOS Lower oesophageal sphincter
Objectives Intragastric balloons allow transient weight loss in obese and overweight patients. The introduction in the stomach and their withdrawal involve iterative endoscopic procedures, usually under sedation or general anesthesia. We investigated the safety and efficacy of a new swallowable intragastric balloon (Obalon®) which can be placed without upper GI endoscopy and allows titration during the treatment period. Methods From January 2012 to April 2012, 17 patients (15 women, 39±9 years, BMI: 31±3 kg/m2) have been included in Brussels and Lyon. Ingestion of the balloon (inserted in a soluble capsule 30 x 15 mm, and connected to a detachable inflation-catheter of 2 Fr in diameter) was performed under fluoroscopic control, and the balloon inflated with 250 cc of gas once in place in the stomach. An additional balloon could be administered at 4 and 8 weeks depending on the tolerance and weight loss. Patients were under PPIs for the duration of the study. The balloons were endoscopically removed under sedation at 12 weeks. Results A balloon could be inserted in all patients; a second balloon was ingested by 16 patients (inability to swallow in 1) between 4 and 5 weeks after the first, and a 3rd balloon ingested between 7 and 9 weeks by 10 patients (no failures of ingestion). The mean time to insert the balloon (ingestion+ inflation) was 8 min (extreme: 4-18). No unexpected or serious adverse events occurred. Epigastric pain/cramping was the most common adverse event occurring in 12 (71%) subjects, 6 resolved without medical therapy, 6 with oral medical therapy and none required hospitalization. Nausea was also reported in 7 (41%) subjects. The endoscopic withdrawal of the balloons was done under sedation without tracheal intubation: the mean duration of the procedure was 14±6 minutes (range: 6-24 min). At the time of withdrawal, no balloon was spontaneously deflated, and no ulcerations were observed with the exception of 1 mild case, possibly unrelated to the device, in a subject who used NSAIDs. Weight loss compared to baseline was statistically significant (p , 0.0001) with a reduction (mean±SD) of 2.2±1.7 kg, 4.0±2.6 kg, 5.8±2.9 kg at 4, 8 and 12 weeks, respectively. Percent Excess Weight Loss was 15.7± 12.7%, 28.1±18.1%, 44.1±29.4% at 4, 8 and 12 weeks, respectively. Conclusions The data from this study demonstrate this new swallowable intragastric balloon to be safe and easy to administrate, well-tolerated and effective in terms of weight loss over a 12 week period.
Tu1208 Provocative Manometry With Postprandial Monitoring Enhances Diagnostic Yield in Patients With Intermittent Symptoms Victor Chedid, Sameer Dhalla, Monica Nandwani, Bani Chander Roland, John O. Clarke, Ellen M. Stein Background: High-resolution esophageal manometry (HREM) is the gold standard for evaluation of esophageal motility disorders. However, symptoms rarely occur during a monitored liquid swallow, especially when symptoms are intermittent. Recent literature supports use of provocative HREM protocols to more reliably induce symptoms and assess motility when "under duress." Our protocol involves patients bringing a meal to be eaten while undergoing prolonged monitoring during and after meal ingestion. We hypothesized that this would provoke symptoms and increase diagnostic yield. Aims: The aims of our study were to determine whether 1) the addition of dedicated postprandial monitoring enhanced diagnostic yield in patients with intermittent symptoms, and whether 2) a 30-minute postprandial monitoring period was sufficient to capture symptoms in the majority of referred patients. Methods: Consecutive patients who underwent HREM with postprandial monitoring at a single academic referral center from January to October 2012 were reviewed. Demographics, initial diagnosis, final diagnosis, number of symptoms, and changes in management were recorded. Patients were encouraged to bring a meal of their choice which would be likely to produce symptoms. All patients underwent standard HREM with 10 liquid swallows. The meal was then ingested while the HREM catheter remained in position for 30 minutes. All symptoms were noted. Results: Out of 458 patients who underwent HREM during the study period, 15 patients (mean age= 52.9, range= 25-80, Females=66.7%) were referred specifically for HREM with extended postprandial monitoring. Indications were: refractory belching (6), atypical GERD (3), regurgitation (3), and intermittent dysphagia (3). Ten of the 15 patients recorded symptoms (belching, dysphagia or chest pressure) during the 30 minute monitoring period. The number of symptoms provoked ranged from 0 to "innumerable" with a median value of 5. Six of the 15 patients had new manometric findings after meal ingestion, that were not evident when taking only liquid swallows, with subsequent changes in both diagnoses and management. New diagnoses detected with dedicated postprandial monitoring included rumination, supragastric belching, gastric belching, and diffuse esophageal spasm. Conclusion: HREM with extended postprandial monitoring enhanced diagnostic yield as compared to conventional HREM. Postprandial monitoring should be considered in patients with intermittent symptoms such as dysphagia or belching, where symptomatic provocation is desired to assure complete evaluation, or in patients for whom rumination is suspected. Thirty minutes appears to be an adequate duration to allow symptom genesis. Prospective evaluation will help determine which subset of symptoms has highest diagnostic yield with this protocol.
AGA Abstracts
Tu1211 Endoscopic Treatment of Post Laparoscopic Sleeve Gastrectomy Fistula : Results From a Multicenter Retrospective Study Dimitri Christophorou, Natalie Funakoshi, Jean-Christophe Valats, Bruno Vedrenne, Frederic Prat, Philippe Bulois, Vincent Maunoury, Sebastien Decoster, Emmanuel Coron, Claire Duflos, Marie-Christine Picot, David Nocca, Paul Bauret, Pierre Blanc Introduction Laparoscopic Sleeve Gastrectomy (LSG) is the most frequently performed bariatric surgery procedure in France. Staple line leak is the main complication, for which healing is difficult to obtain. Aims: To evaluate the effectiveness of endoscopic treatment in the repair of staple line leaks, to describe the various endoscopic techniques used, to identify the predictive factors of healing following endoscopic management. Methods Patients with LSG staple line leaks were included in a multicenter retrospective cohort. Data was collected on therapeutic procedures performed (endoscopic or surgical), treatment complications and time to healing (spontaneous, or following endoscopic or surgical treatment). Predictive factors of healing after endoscopic treatment were evaluated in univariate analysis by a Logrank test, then in a multivariate analysis using a Cox model. The protocol was approved by the research and development committee of the French Digestive Endoscopy Society. Results 104 patients with leaks (83% females, mean age 39.6 years, mean BMI 44.3 kg/m2)
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