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Tu1213 Physiologic Alterations After PerOral Endoscopic Myotomy (POEM) for Achalasia Using High-Resolution Manometry and Impedance Planimetry
Abstracts
depth of EP/LPM (ly+ 1case: 2.7%, V+ 0case: 0%), 16 cases of MM (ly+ 3cases: 18.8%, V+ 3cases: 18.8%) and 11 cases invading into the SM (ly+ 2cases: 18.2%, V+ 2cases 18.2%). We defined cases where the histopathological depth was EP/LPM without lymphovascular invasion as complete curative resection, and cases of MM without lymphovascular invasion as relative curative resection. There were 36 cases (57.8%) of complete curative resection, and 11 cases (17.2%) of relative curative resection, for a total of 47cases (73.4%) of curative resection. Concerning adverse events, postoperative stenosis occurred in 32 cases (50.0%). The rate of stenosis decreased to 37.9% (11/29) after the introduction of polyglycolic acid sheet for the prevention of stenosis in July 2013, compared to 60% (21/35) without preventive measures. Conclusions: Endoscopic submucosal dissection enables a high rate of curative resection with minimal invasiveness even in wide-spreading superficial esophageal cancers. Further research on the prevention of stenosis after ESD is required.
Tu1212 Investigation of Endoscopic Diagnosis in Early Local Recurrence After Definitive Chemoradiotherapy for Esophageal Squamous Cell Carcinoma - From Review of Prior Endoscopic Imaging Yoichi Yamamoto*, Tomonori Yano, Tomohiro Kadota, Satoshi Fujii, Ken Hatogai, Takashi Kojima, Kazuhiro Kaneko National Cancer Center Hospital East, Kashiwa, Chiba, Japan Background: Local recurrence after achieving complete response (CR) with chemoradiotherapy (CRT) for esophageal squamous cell carcinoma (ESCC) is a major problem. We have reported the salvage endoscopic therapies (SET) including endoscopic resection (ER) or photodynamic therapy (PDT) as effective and less invasive treatments for local recurrence (LR). While SET is available only for LR at an early stage, the endoscopic findings of them have not been identified yet. Aims: To clarify the clinical courses of patients (pts) with LR and endoscopic findings of early LR after achieving CR with CRT. Methods: Between January 2008 and June 2012, 167 pts underwent definitive CRT for ESCC in our hospital. Of them, we enrolled the pts who had achieved CR after CRT. Pts who were not followed with endoscopy for six months or longer after achieving CR were excluded. LR was defined as lesions whose biopsy findings were positive for viable cancer cells. We retrospectively analyzed clinical courses after LR, and compared the endoscopic images at LR and prior consecutive endoscopic imaging series in order to clarify the earlier findings of LR. This study was approved by the institutional review board in our institution. Results: Of the 167 pts, 81 achieved CR. Of them, LR was detected in 21 pts (26%). The baseline characteristics of those were as follows: male/female, 20/1; median age, 66 years (range: 54-81); T1/T2/T3/T4, 5/1/13/2. Median duration of the period from achieving CR to detecting LR was 204 days (range: 28-1668). At the diagnosis of LR, their endoscopic findings were submucosal tumor (SMT) like in 10 (48%), deep ulcer in 7 (33%), erosion in 4 (19%) lesions, respectively. Of 21 pts, 11 (52%) were treated with SET (ER: 6, PDT: 5), 6 (29%) were resected surgically, and the remaining 4 (19%) were followed as palliation. Regarding 10 pts with SMT-like, 5 (50%) were treated with SET, whereas the other 5 received surgery or palliation. In 7 pts with deep ulcer, 2 (29%) were treated with SET whereas the other 5 received surgery or palliation. All of 4 pts with erosion underwent SET. During the median follow-up periods of 36 months after LR detection, 3-year survival rate in pts with deep ulcer or with erosion and SMT-like were 28.6% and 63.5%, respectively (pZ0.101). With the review of prior endoscopic imaging, 9 (43%) of 21 pts could be detected earlier findings before LR. In 6 of the 7 pts with deep ulcer, 4 were SMT like and 2 were erosion, and 3 of the 10 pts with SMT-like were detected as smaller SMT like lesions. Furthermore, the median duration between prior imaging detection and LR decision was 163 days (range: 34-296). Conclusion: Earlier detection of LR after CRT enable to treat with less invasive treatment. Findings of SMT like or erosion are very important to detect LR at an early stage, even before decision histologically.
Tu1213 Physiologic Alterations After PerOral Endoscopic Myotomy (POEM) for Achalasia Using High-Resolution Manometry and Impedance Planimetry Amr Ismail*1, Yamile Haito Chavez1, Saowanee Ngamruengphong1, Gulara Hajiyeva1, Yen-I. Chen1, Majidah Bukhari1, Mohamad H. El Zein2, Ahmed A. Messallam3, Ellen M. Stein1, John O. Clarke1, Vivek Kumbhari1, Mouen A. Khashab1 1 Department of Medicine, Johns Hopkins Hospital, Baltimore, MD; 2 University of Toledo, Toledo, OH; 3Emory University, Atlanta, GA Background: Despite well-documented clinical success, there are limited data with regard to objective physiologic alterations such as improved manometric findings and increased esophageal distensibility pre and post POEM. Aims: The primary aim of this study was to assess changes in esophageal motility as a result of POEM in patients with achalasia. The secondary aim was to compare changes in esophageal
AB578 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
distensibility (DI) and correlate these changes with high-resolution manometry (HRM) parameters: 4s integrated relaxation pressure (IRP) and lower esophageal sphincter (LES) resting pressure. Methods: This retrospective study reviewed patients that underwent POEM from 5/2012 to 10/2015 and had complete pre and postprocedure evaluation. Esophageal motility was evaluated via HRM and impedance planimetry (performed before and after POEM). DI was calculated as minimum CSA divided by the corresponding pressure, utilizing balloon volumes at both 30cc and 40cc. By dividing patients into responders and non-responders, we calculated how well HREM and Impedance planimetry values correlate with clinical success. Results: A total of 51 patients (30 M, median age 51 yr) with achalasia were treated with POEM and underwent pre and post POEM esophageal motility testing. The median Eckardt score pre POEM was 8. A total of 25 patients (49%) underwent therapy pre POEM (see Table 1). The mean length of myotomy was 10 cm. Clinical success, defined as Eckardt score <3, was achieved in 43 patients (84.3%). When comparing the physiological characteristics (mean SD) pre and post POEM, there was a significant decrease in IRP (27.45 11.74 vs 11.45 8.21, p<0.05). There was also a significant decrease in LES resting pressure post POEM (39.52 22.09 vs 21.10 15.01, p<0.05). POEM significantly increased DI at 30cc (1.57 1.33 vs 4.60 2.23, p<0.05) and 40cc (1.78 1.85 vs 6.00 2.58, p<0.05) (Table 2). On comparing the percent decrease in IRP to the percent increase in DI at 30cc and 40cc, there was no significant correlation (30cc, coefficient of 0.16 and significance value of 0.37, 40cc: coefficient of 0.21, significance value of 0.243). There was no correlation between decrease in LES resting pressure and increase in DI at 30cc or 40cc (30cc: coefficient of 0.19, significance value of 0.31, 40cc: coefficient of 0.32, significance of 0.07). IRP, LES pressure, 30cc DI, and 40cc DI were poor predictors of success (Significance value: 0.39, 0.48, 0.79, 0.70, respectively). Conclusion: POEM for achalasia results in a significant reduction in LES pressure and IRP via HRM as well as a significant increase in DI via impedance planimetry. However, the parameters derived via HRM (LES pressure, IRP) do not correlate with changes in distensibility measured via impedance planimetry. Parameters derived from both tests are not good predictors of clinical success for POEM. Table 1. Patient characteristics Male: Female Age, median, years (range) Duration of symptoms, mean, months (range) Eckardt score, median (range) Previous treatments, (%) Pneumatic dilation (PD) (%) Endoscopic botulinum toxin injection (EBTI) (%) Both (PD + EBTI) (%) Heller myotomy (%) Achalasia Type I (%) Achalasia Type II (%) Achalasia Type III (%)
30:21 51 (17-88) 4.1 (1-15) 8 (5-11) 25 (49%) 11 (21.6%) 3 (5.9%) 6 (11.7%) 5 (9.8%) 4 (7.8%) 40 (78.4%) 7 (13.8%)
Table 2. HREM and Impedance Planimetry Parameters Variable
Pre-POEM (mean + SD)
Post-POEM (mean + SD)
LES resting pressure (mmHg) 4sIRP (mmHg) Distensibility 30cc Distensibility 40cc
39.52 27.45 1.57 1.78
21.10 11.45 4.60 6.00
(22.09) (11.74) (1.33) (1.85)
(15.01) (8.21) (2.23) (2.58)
P-value < < < <
0.05 0.05 0.05 0.05
Tu1214 Epithelial Cells Tissue Products for Prevention of Post-ESD Complications in the Area of Pharynx Makoto Abe*2,1, Nobuo Kanai1, Keisuke Hori2, Yoshiro Kawahara2, Masayuki Yamato1, Hiroyuki Okada2 1 Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, Tokyo, Japan; 2Department of Gastroenterology, Okayama University Graduate school of Medicine, Dentistry and Pharmaceutical Science, Japan, Okayama, Japan Background: With the development of image enhanced endoscopy, the number of superficial cancer in the oropharynx and hypopharynx detected in the routine endoscopy is increasing. The endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), or endoscopic laryngopharyngeal surgery (ELPS) are performed for these superficial squamous cell carcinomas. These treatment methods are safety and less-invasive than the surgery or the chemo-radiation therapy. But, because of complicated structure of pharynx, when ESD was performed for a lesion near the pyriform sinus, postoperative adhesion and
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depth of EP/LPM (ly+ 1case: 2.7%, V+ 0case: 0%), 16 cases of MM (ly+ 3cases: 18.8%, V+ 3cases: 18.8%) and 11 cases invading into the SM (ly+ 2cases: 18.2%, V+ 2cases 18.2%). We defined cases where the histopathological depth was EP/LPM without lymphovascular invasion as complete curative resection, and cases of MM without lymphovascular invasion as relative curative resection. There were 36 cases (57.8%) of complete curative resection, and 11 cases (17.2%) of relative curative resection, for a total of 47cases (73.4%) of curative resection. Concerning adverse events, postoperative stenosis occurred in 32 cases (50.0%). The rate of stenosis decreased to 37.9% (11/29) after the introduction of polyglycolic acid sheet for the prevention of stenosis in July 2013, compared to 60% (21/35) without preventive measures. Conclusions: Endoscopic submucosal dissection enables a high rate of curative resection with minimal invasiveness even in wide-spreading superficial esophageal cancers. Further research on the prevention of stenosis after ESD is required.
Tu1212 Investigation of Endoscopic Diagnosis in Early Local Recurrence After Definitive Chemoradiotherapy for Esophageal Squamous Cell Carcinoma - From Review of Prior Endoscopic Imaging Yoichi Yamamoto*, Tomonori Yano, Tomohiro Kadota, Satoshi Fujii, Ken Hatogai, Takashi Kojima, Kazuhiro Kaneko National Cancer Center Hospital East, Kashiwa, Chiba, Japan Background: Local recurrence after achieving complete response (CR) with chemoradiotherapy (CRT) for esophageal squamous cell carcinoma (ESCC) is a major problem. We have reported the salvage endoscopic therapies (SET) including endoscopic resection (ER) or photodynamic therapy (PDT) as effective and less invasive treatments for local recurrence (LR). While SET is available only for LR at an early stage, the endoscopic findings of them have not been identified yet. Aims: To clarify the clinical courses of patients (pts) with LR and endoscopic findings of early LR after achieving CR with CRT. Methods: Between January 2008 and June 2012, 167 pts underwent definitive CRT for ESCC in our hospital. Of them, we enrolled the pts who had achieved CR after CRT. Pts who were not followed with endoscopy for six months or longer after achieving CR were excluded. LR was defined as lesions whose biopsy findings were positive for viable cancer cells. We retrospectively analyzed clinical courses after LR, and compared the endoscopic images at LR and prior consecutive endoscopic imaging series in order to clarify the earlier findings of LR. This study was approved by the institutional review board in our institution. Results: Of the 167 pts, 81 achieved CR. Of them, LR was detected in 21 pts (26%). The baseline characteristics of those were as follows: male/female, 20/1; median age, 66 years (range: 54-81); T1/T2/T3/T4, 5/1/13/2. Median duration of the period from achieving CR to detecting LR was 204 days (range: 28-1668). At the diagnosis of LR, their endoscopic findings were submucosal tumor (SMT) like in 10 (48%), deep ulcer in 7 (33%), erosion in 4 (19%) lesions, respectively. Of 21 pts, 11 (52%) were treated with SET (ER: 6, PDT: 5), 6 (29%) were resected surgically, and the remaining 4 (19%) were followed as palliation. Regarding 10 pts with SMT-like, 5 (50%) were treated with SET, whereas the other 5 received surgery or palliation. In 7 pts with deep ulcer, 2 (29%) were treated with SET whereas the other 5 received surgery or palliation. All of 4 pts with erosion underwent SET. During the median follow-up periods of 36 months after LR detection, 3-year survival rate in pts with deep ulcer or with erosion and SMT-like were 28.6% and 63.5%, respectively (pZ0.101). With the review of prior endoscopic imaging, 9 (43%) of 21 pts could be detected earlier findings before LR. In 6 of the 7 pts with deep ulcer, 4 were SMT like and 2 were erosion, and 3 of the 10 pts with SMT-like were detected as smaller SMT like lesions. Furthermore, the median duration between prior imaging detection and LR decision was 163 days (range: 34-296). Conclusion: Earlier detection of LR after CRT enable to treat with less invasive treatment. Findings of SMT like or erosion are very important to detect LR at an early stage, even before decision histologically.
Tu1213 Physiologic Alterations After PerOral Endoscopic Myotomy (POEM) for Achalasia Using High-Resolution Manometry and Impedance Planimetry Amr Ismail*1, Yamile Haito Chavez1, Saowanee Ngamruengphong1, Gulara Hajiyeva1, Yen-I. Chen1, Majidah Bukhari1, Mohamad H. El Zein2, Ahmed A. Messallam3, Ellen M. Stein1, John O. Clarke1, Vivek Kumbhari1, Mouen A. Khashab1 1 Department of Medicine, Johns Hopkins Hospital, Baltimore, MD; 2 University of Toledo, Toledo, OH; 3Emory University, Atlanta, GA Background: Despite well-documented clinical success, there are limited data with regard to objective physiologic alterations such as improved manometric findings and increased esophageal distensibility pre and post POEM. Aims: The primary aim of this study was to assess changes in esophageal motility as a result of POEM in patients with achalasia. The secondary aim was to compare changes in esophageal
AB578 GASTROINTESTINAL ENDOSCOPY Volume 83, No. 5S : 2016
distensibility (DI) and correlate these changes with high-resolution manometry (HRM) parameters: 4s integrated relaxation pressure (IRP) and lower esophageal sphincter (LES) resting pressure. Methods: This retrospective study reviewed patients that underwent POEM from 5/2012 to 10/2015 and had complete pre and postprocedure evaluation. Esophageal motility was evaluated via HRM and impedance planimetry (performed before and after POEM). DI was calculated as minimum CSA divided by the corresponding pressure, utilizing balloon volumes at both 30cc and 40cc. By dividing patients into responders and non-responders, we calculated how well HREM and Impedance planimetry values correlate with clinical success. Results: A total of 51 patients (30 M, median age 51 yr) with achalasia were treated with POEM and underwent pre and post POEM esophageal motility testing. The median Eckardt score pre POEM was 8. A total of 25 patients (49%) underwent therapy pre POEM (see Table 1). The mean length of myotomy was 10 cm. Clinical success, defined as Eckardt score <3, was achieved in 43 patients (84.3%). When comparing the physiological characteristics (mean SD) pre and post POEM, there was a significant decrease in IRP (27.45 11.74 vs 11.45 8.21, p<0.05). There was also a significant decrease in LES resting pressure post POEM (39.52 22.09 vs 21.10 15.01, p<0.05). POEM significantly increased DI at 30cc (1.57 1.33 vs 4.60 2.23, p<0.05) and 40cc (1.78 1.85 vs 6.00 2.58, p<0.05) (Table 2). On comparing the percent decrease in IRP to the percent increase in DI at 30cc and 40cc, there was no significant correlation (30cc, coefficient of 0.16 and significance value of 0.37, 40cc: coefficient of 0.21, significance value of 0.243). There was no correlation between decrease in LES resting pressure and increase in DI at 30cc or 40cc (30cc: coefficient of 0.19, significance value of 0.31, 40cc: coefficient of 0.32, significance of 0.07). IRP, LES pressure, 30cc DI, and 40cc DI were poor predictors of success (Significance value: 0.39, 0.48, 0.79, 0.70, respectively). Conclusion: POEM for achalasia results in a significant reduction in LES pressure and IRP via HRM as well as a significant increase in DI via impedance planimetry. However, the parameters derived via HRM (LES pressure, IRP) do not correlate with changes in distensibility measured via impedance planimetry. Parameters derived from both tests are not good predictors of clinical success for POEM. Table 1. Patient characteristics Male: Female Age, median, years (range) Duration of symptoms, mean, months (range) Eckardt score, median (range) Previous treatments, (%) Pneumatic dilation (PD) (%) Endoscopic botulinum toxin injection (EBTI) (%) Both (PD + EBTI) (%) Heller myotomy (%) Achalasia Type I (%) Achalasia Type II (%) Achalasia Type III (%)
30:21 51 (17-88) 4.1 (1-15) 8 (5-11) 25 (49%) 11 (21.6%) 3 (5.9%) 6 (11.7%) 5 (9.8%) 4 (7.8%) 40 (78.4%) 7 (13.8%)
Table 2. HREM and Impedance Planimetry Parameters Variable
Pre-POEM (mean + SD)
Post-POEM (mean + SD)
LES resting pressure (mmHg) 4sIRP (mmHg) Distensibility 30cc Distensibility 40cc
39.52 27.45 1.57 1.78
21.10 11.45 4.60 6.00
(22.09) (11.74) (1.33) (1.85)
(15.01) (8.21) (2.23) (2.58)
P-value < < < <
0.05 0.05 0.05 0.05
Tu1214 Epithelial Cells Tissue Products for Prevention of Post-ESD Complications in the Area of Pharynx Makoto Abe*2,1, Nobuo Kanai1, Keisuke Hori2, Yoshiro Kawahara2, Masayuki Yamato1, Hiroyuki Okada2 1 Institute of Advanced Biomedical Engineering and Science, Tokyo Women’s Medical University, Tokyo, Japan; 2Department of Gastroenterology, Okayama University Graduate school of Medicine, Dentistry and Pharmaceutical Science, Japan, Okayama, Japan Background: With the development of image enhanced endoscopy, the number of superficial cancer in the oropharynx and hypopharynx detected in the routine endoscopy is increasing. The endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), or endoscopic laryngopharyngeal surgery (ELPS) are performed for these superficial squamous cell carcinomas. These treatment methods are safety and less-invasive than the surgery or the chemo-radiation therapy. But, because of complicated structure of pharynx, when ESD was performed for a lesion near the pyriform sinus, postoperative adhesion and
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