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Usefulness of Temporary Stenting for Refractory Benign Esophageal Strictures: Preliminary Study
Abstracts
S1169 Are Lifestyle Measures Effective in Patients with Gastroesophageal Reflux Disease? An Evidence-Based Approach Tonya Kaltehbach, Seth Crockett, Lauren Gerson Background: Lifestyle measures are first line therapy for patients presenting with gastroesophageal reflux disease (GERD), including tobacco and alcohol abstinence, weight loss, elevation of the head of the bed (HOB), and cessation of spicy foods, chocolate, caffeine, and late night meals. Implementation of lifestyle measures may impair quality of life. We performed an evidence-based approach in order to determine the efficacy of lifestyle measures for GERD management. Methods: We used PubMed and Ovid to perform a literature search from 1975-2004 with keywords: GERD, tobacco, smoking, alcohol, obesity, weight loss, caffeine or coffee, citrus, chocolate, spicy food, head of bed elevation, and late-evening meal. Each study was reviewed by 2 reviewers assigning a rating: Evidence A, randomized clinical trials; Evidence B, cohort or case-control studies; Evidence C, case reports or flawed clinical trials; Evidence D, investigator experience; Evidence E, insufficient information. Results: We screened over 600 studies, and identified a total of 67 relevant studies (Table). Of the 67 trials, only 37 (55%) examined the impact on GERD after implementation of the lifestyle measure. While there was physiologic evidence that tobacco, alcohol, chocolate, and high fat meals decrease lower esophageal sphincter pressure (LESP), there was no published evidence for efficacy of dietary measures. Tobacco cessation was not associated with improvement in pH profiles or symptoms (Evidence-B), while alcohol cessation improved symptoms (Evidence-B). Weight loss improved both pH profiles and symptoms (Evidence-B). HOB elevation improved overall time pH ! 4.0 (EvidenceB). Conclusions: Weight loss and HOB elevations are effective lifestyle interventions for GERD. Alcohol cessation may improve GERD symptoms. There is no evidence supporting an improvement in GERD after cessation of tobacco or other dietary measures.
S1170 Usefulness of Temporary Stenting for Refractory Benign Esophageal Strictures: Preliminary Study Hyun Jeong Kim, In Seop Jung, Chang Beom Ryu, Su Jin Hong, Jin Oh Kim, Joo Young Cho, Joon Seong Lee, Moon Sung Lee, Chan Sup Shim, Boo Sung Kim Background: Endoscopic dilation or surgery are considered as the treatment for benign esophageal strictures. However, there are refractory cases to multiple dilations or surgery which has high rates of morbidity and mortality. Aim: To evaluate the efficacy and usefulness of temporary stenting in management of benign esophageal strictures, refractory to multiple endoscopic dilations. Method: Our prospective study included 9 patients with benign esophageal strictures, refractory to multiple endoscopic dilations from March 2002 to May 2004. We inserted full-covered metal stent which was observed by endoscopy every 1-4 wks. We retrieved the stent immediately when there was hyperproliferative tissue protruding over the stent and followed-up by endoscopy with symptom questionnaires (1, 4 wks, then every 3 months). We reinserted the stent in restricture by endoscopy and repeated the whole procedure again. Effectiveness was defined as ability to swallow soft food during follow-up after retrieval of stent. Result: All 9 patients (1 woman, 8 men, mean age 57 years, 6 post-operative, 3 corrosive) completed the stent placement. Successful stenting and retrieval was possible in 6 patients (4 post-operative, 2 corrosive, all 14 sessions). They were followed-up for 18.3 months (range 8-36). The mean initial dysphagia score was 2.7 (range 2-4) and the post-retrieval score was 1. There were no complications during
AB134 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
the procedures. However 2 stents migrated during the follow-up period. The mean frequency of stenting and retrieval was 2.7 sessions (range 1-4), mean duration of placement was 15.1 days (range 3-35) and mean interval of re-stenting was 11.3 days (range 0-35). Unsuccessful 3 patients had lost to follow-up. Conclusions: Our results suggest that the time of stent-retrieval is important for successful esophageal dilation. The stent should be retrieved must be just before when the granulation tissue is seen protruding over the stent. The temporary esophageal stenting may be a possible mode of management in severe, benign esophageal strictures. Key words: refractory benign esophageal stricture, temporary stenting.
S1171 Short Segment Hiatal Hernia: Is It a Clinically Significant Entity? Jin Yong Kim, Jong-Jae Park, Jae Seon Kim, Jong Eun Yeon, Kwan Soo Byun, Young-Tae Bak Background: It is a well accepted idea that hiatal hernia (HH) has a very important contributory role for the development of GERD. However, the clinical significance of small simple sliding HH has been less well studied and still is not clear. Many patients with small HH¡s are believed to be asymptomatic and clinically insignificant. Aim: This study was done to clarify the clinical significance of short segment (i.e. shorter than 2.0 cm in length) HH (SSHH), especially in relation to clinically significant GERD. Methods: Consecutive 4592 cases (M:F 2076:2516, median age 49 years with interquartile range 39~60 years) who underwent their initial routine diagnostic UGI endoscopy at our hospital from various indications were included. Presence and length of sliding HH were determined in each case during insertion of the endoscope while in quiet breathing without retching. Age, gender, presence of erosive esophagitis (EE), and presence of endoscopic columnar-lined esophagus (CLE) were analyzed according to the observed lengths of HH. Among them, 219 cases underwent ambulatory esophageal pH monitoring, and the results were also analyzed. Results: Among 4592 cases, 4164 cases (90.7%) had no HH, 255 cases (5.6%) had SSHH, and 173 cases (3.8%) had long segment HH (LSHH). More males were found in SSHH and LSHH groups than in non-HH group. Ages were older in LSHH group than in other groups. EE was found in 198 cases (4.8%) of non-HH group, 56 cases (22.0%) of SSHH group, and 64 cases (37.0%) of LSHH group (p ! 0.001 between groups). CLE was found in 598 cases (14.4%) of non-HH group, 93 cases (36.5%), and 42 cases (24.3%) (p ! 0.001 between non-HH group and other groups, p Z 0.008 between SSHH and LSHH groups). High Johnson-DeMeester score was significantly less commonly found in non-HH group (26.9%) than in other groups (54.2%, p Z 0.006, in SSHH group and 53.8%, p Z 0.038, in LSHH group), but no difference was noted between SSHH and LSHH groups. Conclusion: LSHH is not a clinically silent and innocent entity, but it is deserved to be accused as a clinically significant pathologic entity quite similar to LSHH as far as GERD is concerned.
S1172 Evaluation of Gastroesophageal Reflux Disease by Capsule Endoscopy Fumiaki Kitahara, Nobuyuaki Enomoto, Rome Jutabha Aims: Recently an evaluation of esophageal disease by capsule endoscopy was reported. Aim of this report is to determine usefulness of capsule endoscopic images for gastroesophageal reflux disease (GERD) and Barrett-fs esophagus. Methods: We performed a retrospective analysis of 98 patients who underwent capsule endoscopy from 10/2003-05/2004 for obscure gastrointestinal bleeding. Results: In 98 patients, the median capsule endoscopy exposure time was 2s (range 0-169s; median of 4 pictures, range 0-338), excluding two patients with extremely delayed esophageal transit (esophageal times: 65 and 68 min); at least one image of the Z-line was obtained in 83 cases (84.7%), but adequate assessment of more than 50%, 75% and 100% of the circumference of the distal esophagus was possible in 79 (95.2%), 55 (66.3%), and 26 (31.3%) of these cases, respectively. And we performed the diagnosis of GERD and Barrett-fs esophagus in 29 cases (34.9%) and 2 cases (2.5%), respectively. Conclusions: It is possible to evaluate distal esophagus status by capsule endoscopy around 85% of all cases, and to diagnose GERD and Barrett’s esophagus around 95% of these cases. Distal esophageal assessment by capsule endoscopy with the aim of providing an easy screening method for reflux lesion is feasible.
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S1169 Are Lifestyle Measures Effective in Patients with Gastroesophageal Reflux Disease? An Evidence-Based Approach Tonya Kaltehbach, Seth Crockett, Lauren Gerson Background: Lifestyle measures are first line therapy for patients presenting with gastroesophageal reflux disease (GERD), including tobacco and alcohol abstinence, weight loss, elevation of the head of the bed (HOB), and cessation of spicy foods, chocolate, caffeine, and late night meals. Implementation of lifestyle measures may impair quality of life. We performed an evidence-based approach in order to determine the efficacy of lifestyle measures for GERD management. Methods: We used PubMed and Ovid to perform a literature search from 1975-2004 with keywords: GERD, tobacco, smoking, alcohol, obesity, weight loss, caffeine or coffee, citrus, chocolate, spicy food, head of bed elevation, and late-evening meal. Each study was reviewed by 2 reviewers assigning a rating: Evidence A, randomized clinical trials; Evidence B, cohort or case-control studies; Evidence C, case reports or flawed clinical trials; Evidence D, investigator experience; Evidence E, insufficient information. Results: We screened over 600 studies, and identified a total of 67 relevant studies (Table). Of the 67 trials, only 37 (55%) examined the impact on GERD after implementation of the lifestyle measure. While there was physiologic evidence that tobacco, alcohol, chocolate, and high fat meals decrease lower esophageal sphincter pressure (LESP), there was no published evidence for efficacy of dietary measures. Tobacco cessation was not associated with improvement in pH profiles or symptoms (Evidence-B), while alcohol cessation improved symptoms (Evidence-B). Weight loss improved both pH profiles and symptoms (Evidence-B). HOB elevation improved overall time pH ! 4.0 (EvidenceB). Conclusions: Weight loss and HOB elevations are effective lifestyle interventions for GERD. Alcohol cessation may improve GERD symptoms. There is no evidence supporting an improvement in GERD after cessation of tobacco or other dietary measures.
S1170 Usefulness of Temporary Stenting for Refractory Benign Esophageal Strictures: Preliminary Study Hyun Jeong Kim, In Seop Jung, Chang Beom Ryu, Su Jin Hong, Jin Oh Kim, Joo Young Cho, Joon Seong Lee, Moon Sung Lee, Chan Sup Shim, Boo Sung Kim Background: Endoscopic dilation or surgery are considered as the treatment for benign esophageal strictures. However, there are refractory cases to multiple dilations or surgery which has high rates of morbidity and mortality. Aim: To evaluate the efficacy and usefulness of temporary stenting in management of benign esophageal strictures, refractory to multiple endoscopic dilations. Method: Our prospective study included 9 patients with benign esophageal strictures, refractory to multiple endoscopic dilations from March 2002 to May 2004. We inserted full-covered metal stent which was observed by endoscopy every 1-4 wks. We retrieved the stent immediately when there was hyperproliferative tissue protruding over the stent and followed-up by endoscopy with symptom questionnaires (1, 4 wks, then every 3 months). We reinserted the stent in restricture by endoscopy and repeated the whole procedure again. Effectiveness was defined as ability to swallow soft food during follow-up after retrieval of stent. Result: All 9 patients (1 woman, 8 men, mean age 57 years, 6 post-operative, 3 corrosive) completed the stent placement. Successful stenting and retrieval was possible in 6 patients (4 post-operative, 2 corrosive, all 14 sessions). They were followed-up for 18.3 months (range 8-36). The mean initial dysphagia score was 2.7 (range 2-4) and the post-retrieval score was 1. There were no complications during
AB134 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
the procedures. However 2 stents migrated during the follow-up period. The mean frequency of stenting and retrieval was 2.7 sessions (range 1-4), mean duration of placement was 15.1 days (range 3-35) and mean interval of re-stenting was 11.3 days (range 0-35). Unsuccessful 3 patients had lost to follow-up. Conclusions: Our results suggest that the time of stent-retrieval is important for successful esophageal dilation. The stent should be retrieved must be just before when the granulation tissue is seen protruding over the stent. The temporary esophageal stenting may be a possible mode of management in severe, benign esophageal strictures. Key words: refractory benign esophageal stricture, temporary stenting.
S1171 Short Segment Hiatal Hernia: Is It a Clinically Significant Entity? Jin Yong Kim, Jong-Jae Park, Jae Seon Kim, Jong Eun Yeon, Kwan Soo Byun, Young-Tae Bak Background: It is a well accepted idea that hiatal hernia (HH) has a very important contributory role for the development of GERD. However, the clinical significance of small simple sliding HH has been less well studied and still is not clear. Many patients with small HH¡s are believed to be asymptomatic and clinically insignificant. Aim: This study was done to clarify the clinical significance of short segment (i.e. shorter than 2.0 cm in length) HH (SSHH), especially in relation to clinically significant GERD. Methods: Consecutive 4592 cases (M:F 2076:2516, median age 49 years with interquartile range 39~60 years) who underwent their initial routine diagnostic UGI endoscopy at our hospital from various indications were included. Presence and length of sliding HH were determined in each case during insertion of the endoscope while in quiet breathing without retching. Age, gender, presence of erosive esophagitis (EE), and presence of endoscopic columnar-lined esophagus (CLE) were analyzed according to the observed lengths of HH. Among them, 219 cases underwent ambulatory esophageal pH monitoring, and the results were also analyzed. Results: Among 4592 cases, 4164 cases (90.7%) had no HH, 255 cases (5.6%) had SSHH, and 173 cases (3.8%) had long segment HH (LSHH). More males were found in SSHH and LSHH groups than in non-HH group. Ages were older in LSHH group than in other groups. EE was found in 198 cases (4.8%) of non-HH group, 56 cases (22.0%) of SSHH group, and 64 cases (37.0%) of LSHH group (p ! 0.001 between groups). CLE was found in 598 cases (14.4%) of non-HH group, 93 cases (36.5%), and 42 cases (24.3%) (p ! 0.001 between non-HH group and other groups, p Z 0.008 between SSHH and LSHH groups). High Johnson-DeMeester score was significantly less commonly found in non-HH group (26.9%) than in other groups (54.2%, p Z 0.006, in SSHH group and 53.8%, p Z 0.038, in LSHH group), but no difference was noted between SSHH and LSHH groups. Conclusion: LSHH is not a clinically silent and innocent entity, but it is deserved to be accused as a clinically significant pathologic entity quite similar to LSHH as far as GERD is concerned.
S1172 Evaluation of Gastroesophageal Reflux Disease by Capsule Endoscopy Fumiaki Kitahara, Nobuyuaki Enomoto, Rome Jutabha Aims: Recently an evaluation of esophageal disease by capsule endoscopy was reported. Aim of this report is to determine usefulness of capsule endoscopic images for gastroesophageal reflux disease (GERD) and Barrett-fs esophagus. Methods: We performed a retrospective analysis of 98 patients who underwent capsule endoscopy from 10/2003-05/2004 for obscure gastrointestinal bleeding. Results: In 98 patients, the median capsule endoscopy exposure time was 2s (range 0-169s; median of 4 pictures, range 0-338), excluding two patients with extremely delayed esophageal transit (esophageal times: 65 and 68 min); at least one image of the Z-line was obtained in 83 cases (84.7%), but adequate assessment of more than 50%, 75% and 100% of the circumference of the distal esophagus was possible in 79 (95.2%), 55 (66.3%), and 26 (31.3%) of these cases, respectively. And we performed the diagnosis of GERD and Barrett-fs esophagus in 29 cases (34.9%) and 2 cases (2.5%), respectively. Conclusions: It is possible to evaluate distal esophagus status by capsule endoscopy around 85% of all cases, and to diagnose GERD and Barrett’s esophagus around 95% of these cases. Distal esophageal assessment by capsule endoscopy with the aim of providing an easy screening method for reflux lesion is feasible.
www.mosby.com/gie