Improvement In Dysphagia Score Research Articles

Combined brachytherapy and external beam radiation: an effective approach for palliation in esophageal cancer.

PurposePalliation of dysphagia is a challenge in advanced esophageal cancer. The addition of external beam radiotherapy (EBRT) to intraluminal brachytherapy (ILBT) has shown significant improvement in dysphagia relief and symptom scores. The aim of the present study was to evaluate the efficacy of combined use of ILBT and EBRT.Material and methodsThe medical records of 148 patients with advanced/metastatic esophageal cancer were screened from January 2008 to April 2014, and 74 patients were found eligible for the analysis. All patients received two fractions of 8 Gy each of ILBT, followed by EBRT. Patients were assessed for the symptom scores of dysphagia, odynophagia, regurgitation, and chest pain and weight was recorded periodically.ResultsFor a median follow-up of 6 months, the median OS was 9.5 months (95% CI: 7.5-10.5). The median dysphagia free survival was 6 months (95% CI: 4.8-7.1). The scores for dysphagia significantly improved after completion of 1st ILBT (p = 0.000), 2nd ILBT (p = 0.000), and at 3 months after EBRT compared to ILBT (p = 0.02). Overall 47% had improvement in dysphagia scores and 35% maintained the improvement of scores till last follow up. There was significant improvement in weight after completion of ILBT (p = 0.001) and at 3 months after completion of EBRT (p = 0.00). Twenty nine (39%) patients required nasogastric (NGT) insertions and 12 (16%) needed hospitalization for supportive care. 36.4% had complications in the form of stricture (27%), fistula (5.4%), and bleeding (4%).ConclusionsPalliative radiotherapy is an effective alternative for palliation of dysphagia with improvement in symptom scores being evident and sustained. The results of this clinical audit were comparable with those from the trial setting.

Quality of life assessment after peroral endoscopic myotomy

Peroral Endoscopic Myotomy (POEM) is a promising treatment option for motor disorders of the esophagus. The purpose of this study was to assess quality of life (QOL) postoperatively. All patients who presented to our institution for surgical treatment of achalasia after 2011 were asked to complete QOL (SF-36), dysphagia, reflux severity index, and GERD questionnaires in clinic preoperatively and postoperatively at approximately 3 weeks, 6 months, and 1 year. Those patients who underwent a POEM procedure (n = 37) demonstrated a significant improvement in dysphagia scores, reflux severity scores, and GERD scores (p < 0.05) at each time point. SF-36 questionnaires specifically demonstrated a significant improvement in several concepts. At 3 weeks, emotional well-being scores were significantly higher (p = 0.006). At 6 months, the following concepts were significantly higher: emotional well-being (p = 0.039), social functioning (p = 0.038), and general health (p = 0.029). At 1 year, the following concepts were significantly higher: role limitations due to physical health (p = 0.001) and social functioning (p = 0.002). There is a significant improvement in several measures of QOL after POEM, which is comparable to that seen after laparoscopic Heller myotomy.

Safety implications of oesophageal stents used for the palliation of dysphagia in patients undergoing neoadjuvant therapy for oesophageal malignancy-authors' reply.

Sirs, We thank Drs. Jones and Griffiths for their interest in our article (1). They have raised some valid points against the use of oesophageal stents used for the palliation of dysphagia in patients undergoing neoadjuvant therapy for oesophageal cancer. There was significant improvement in dysphagia scores observed in our analysis. Their concerns are based on reports of life threatening complications like oesophago-tracheobronchial fistulae, acute oesophageal perforation and migration with small bowel obstruction or perforation (2-4). In our paper we examined patients with operable disease which is a different cohort of patients that had the life threatening complications. The latter group had locally advanced disease or extensive metastatic disease and were having palliative therapy (3). After our study was published, two more studies have been published demonstrating significant improvement in quality of life related to dysphagia and increase in oral alimentation in patients having neoadjuvant therapy prior to planned oesophageal resection (5,6). The incidence of oesophageal erosion, fistula or perforation was zero. Our study does not address the use of stents for palliation, hence, the observations from Shenfine et al. (7) are not be applicable. Recently, Zhu et al. (8) performed a multicentre, single-blind and randomized phase 3 trial with 160 unresectable oesophageal cancers from 16 hospitals in China that compared conventional stents versus stents loaded with 125Iodine seeds. There was a survival benefit of 30 days reported with stents loaded with 125Iodine seeds. The stents loaded with 125Iodine seeds holds an interesting future in unresectable oesophageal cancer therapy, but again is examining the use of stents for palliation. The potential limitation of this meta-analysis could be the small number of studies and sample size included for the analysis. The other main limitation of this meta-analysis is the lack of patient level data, particularly survival data which precluded us from performing a robust analysis. The considerable variations in reported outcomes of patients besides poor outcomes have not been reported sufficiently in the literature and could be a cofounding factor. Obviously, all retrospective studies have the drawback that can be overcome only by a large well designed prospective, randomized controlled trial and the present meta-analysis provides an insight into the evidence available today. We agree that a robust randomized controlled trial is vital for evaluating the role of oesophageal stents compared to the use of nasogastric feeding in patients undergoing neoadjuvant therapy for oesophageal cancer. Until that time either removable stents or the insertion of a nasogastric tube would be an appropriate choice for patients requiring nutritional support.

The role of endoscopy in the evaluation and management of dysphagia

The role of endoscopy in the evaluation and management of dysphagia

Mitomycin-C: ‘a ray of hope’ in refractory corrosive esophageal strictures

Increasingly frequent dilation may become a self-defeating cycle in refractory stricture as recurrent trauma enhance, scar formation, and ultimately recurrence and potential worsening of the stricture. In 12 patients of caustic induced esophageal stricture, who failed to respond despite rigorous dilatation regimen for more than one year, a trial of topical mitomycin-C application to improve dilatation results was undertaken, considering the recently reported efficacy and safety of this agent. Mitomycin-C was applied for 2-3 minutes at the strictured esophageal segment after dilation with wire-guided Savary-Gilliard dilator. Patient was kept nil by mouth for 2-3 hours. After 4-6 sessions of mitomycin-C treatment, resolution of symptoms and significant improvement in dysphagia score and periodic dilatation index was seen in all 12 patients. Mitomycin-C topical application may be a useful strategy in refractory corrosive esophageal strictures and salvage patients from surgery.

What Is the Optimal Management of Dysphagia in Metastatic Esophageal Cancer?

Hanna et al. investigated the improvement in dysphagia score (ds) in inoperable esophageal cancer treated with endoluminal stenting or radiation therapy. [...]

Empiric Esophageal Dilatation for Nonobstructive Dysphagia

Purpose: Dysphagia is one of the most common complaints encountered in gastroenterology. Endoscopy frequently does not reveal any obstruction. Empiric esophageal dilatation is performed in many of these cases for symptomatic relief. The purpose of this prospective study is to determine if there is a significant, sustained response to esophageal dilatation in cases with nonobstructive dysphagia. Methods: Patients presenting with dysphagia who had no obstruction demonstrated upon endoscopy and had empiric dilatation of esophagus were included in the study. Dilatation was achieved utilizing 48 F wire guided Savary dilators in most cases. 102 patients with dysphagia were enrolled. Dysphagia scores [1] were recorded before the procedure and at 2 months, 6 months and 18 months after the procedure. An increase in dysphagia score of one or more was considered an improvement. Number of patients using a proton pump inhibitor (PPI) also was recorded. Paired sample t-test was used to determine the significance of response to the dilatation at the 2-month, 6-month and 18 month intervals. Results: Of the 102 patients enrolled, 88 reported improvement at the 2 month follow up. At the 6 month follow up, 78 patients reported an improvement. At 18 month interval, 68 reported an improvement 18 patients reported no improvement and 16 patients were lost to follow up. Results for 3 follow up intervals achieved statistical significance [Table 1]. Analysis of biopsy results was done. 17 patients had inflammatory changes and 12 had reactive changes. No cases with eosinophilic esophagitis were found. When the study commenced 85 of 102 were on PPI and at closing of study 74 of 86 patients were on proton pump inhibitors (PPI). Of the 12 who were not on PPI, all improved with dilatation alone. No complications were reported from the procedure.Table 1: Results of paired sample t testConclusion: The number of patients reporting improvement in dysphagia scores at all three follow up intervals after dilatation reached statistical significance. Based on the sustained response to the procedure and the lack of complications it can be concluded that esophageal dilatation offers significant relief for non obstructive dysphagia.

The impact of prior radiotherapy on fatal complications after self-expandable metallic stents (SEMS) for malignant dysphagia due to esophageal carcinoma

The esophageal stent has been demonstrated to serve as a safe and effective palliative treatment for advanced inoperable esophageal carcinoma. However, the safety of esophageal stents in patients with prior radiotherapy (RT) remains debated. This article aims to investigate the impact of prior RT on the incidence of fatal complications after self-expandable metallic stents for palliation of malignant dysphagia because of esophageal carcinoma. Between January 2007 and July 2010, 93 patients with malignant dysphagia because of esophageal carcinoma underwent placement of self-expandable metallic stents in our hospital. Patients were retrospectively separated into two groups: patients with RT before stent placement (RT group, n=57) and patients with no treatment before stent placement (no RT group, n=35).The median survival after stent placement was 77 days (7-842 days) in the RT group and 246 days (15-878 days) in the no RT group. Improvement in dysphagia score was similar in both groups. The fatal complications included fatal gastrointestinal hemorrhage and uncontrolled pneumonia. The incidence of fatal gastrointestinal hemorrhage and uncontrolled pneumonia were 28.1% and 5.7% (P=0.009), 28.1% and 5.7% (P=0.009), respectively. Logistic regression analysis showed a significant interaction between prior RT and fatal gastrointestinal hemorrhage (relative risk 7.82, 95% confidence interval 1.54-39.61; P=0.013). Mortality of massive hemorrhage was 5.7% (2/35), 0% (0/4), 12.5% (3/24), and 44.8% (13/29), respectively, in patients who received 0, 1Gy∼49Gy, 50Gy∼60Gy, and >60Gy (χ(2) =17.761; P=0.000). Logistic regression analysis disclosed prior RT did not significantly increase the risk of uncontrolled pneumonia (relative risk 1.47, 95% confidence interval 0.21-10.12; P=0.697).

Intraluminal high-dose-rate brachytherapy for palliation of dysphagia in cancer of the esophagus: initial experience at a single UK center

Esophageal cancer tends to present with advanced disease, and the majority of patients are suitable only for palliative treatment at diagnosis. Dysphagia is the most common presenting symptom and significantly undermines quality of life. High-dose-rate intraluminal brachytherapy (ILBT) has been an option for the palliation of dysphagia for many years and has been used at our center since 2006. Experience was presented in terms of improvement of dysphagia and survival. Patients were identified from the local radiotherapy database. Original treatment sheets and clinical notes were reviewed retrospectively to obtain treatment details, pretreatment and post-treatment dysphagia scores, and survival information. Between January 2006 and January 2010, 21 patients of median age 77 years with a mean pretreatment dysphagia score of 2.5 underwent ILBT for esophageal cancer. All received 12 Gy in a single fraction. Thirteen (62%) had adenocarcinoma and eight (38%) squamous cell carcinoma. Four (19%) tumors were in the mid-esophagus and 17 (81%) in the lower esophagus. Eight had extension of tumor into the gastroesophageal junction. Seven patients (33%) received chemotherapy as first-line treatment prior to brachytherapy. Nineteen patients had clear documentation of dysphagia scores both pretreatment and post-treatment, and the improvement overall was significant (P= 0.04). Ten patients (53%) had an improvement in dysphagia score. Five of these (50%) went on to require further endoscopic intervention due to disease progression. Median duration of response was 4 months. Of the nonresponders, six (67%) went on to require further endoscopic intervention. No patients experienced documented toxicity aside from a short-lived acute esophagitis. Median survival from date of diagnosis was 12 months and from treatment date was 5 months (1-32 months). In our series of elderly patients with significant dysphagia, ILBT was a well-tolerated and effective treatment. It should be considered as a palliative option in esophageal cancer.

A new retrievable nitinol alloy stents for treatment of refractory benign esophageal strictures

To explore long-term effect of the treatment of refractory benign esophageal strictures with a novel retrievable fully covered stent made of nitinol alloy. From November 2009 to May 2011, the stents were placed in 8 patients with refractory benign esophageal strictures in the Department of Thoracic Surgery at the Cancer Center of Sun Yat-sen University. Esophago-gastro-duodenoscopy and barium swallow examinations were performed respectively on the 1st, 7th, 30th, 60th day after implantations of the stents and 1,2,3,6 months or even longer after removal of the stents in order to assess the long-term effect on the improvement of dysphagia and the development of complications. The stents were successful deployed in all the patients. The dysphagia scores were improved instantly and significantly as compared to the preoperative scores(P<0.05). Seven patients had long-term improvement of dysphagia. The dwelling time of all the stents ranged from 4 to 60 weeks, with a median of 16.8 weeks. Six patients had their stent removed after a dwelling time of 4 to 18 weeks(median 9.7 weeks). The follow-up period was 1.5-9 months (median 6.1 months). The improvement of dysphagia was also significant during follow-up after removal of the stents(P<0.05). At the most recent follow up, two patients still had the stent in place. The first one has already been followed up for 15 months and was still on regular diet. The other one experienced improvement of dysphagia score up to two months after placement, but downgraded to 3 by the third month. Relapse of stenosis occurred in 1 patient, migration in 2 patients, and tissue hyperplasia in 3 patients, of whom 2 developed inward growth of granulation tissue due to the rupture of the covering membrane. The new retrievable fully covered stent made of nitinol alloy significantly improves the swallowing function of patients with intractable benign esophageal strictures after implantation and after removal of the stents, with low incidence of long-term restenosis. However, the high rate of migrations and the poor quality of the covering membrane further implies that the design of the new stent still needs to be improved.

A pilot study of fully covered self-expandable metal stents prior to neoadjuvant therapy for locally advanced esophageal cancer

Self-expandable metal stents (SEMS) have been mostly reserved for palliation of dysphagia because of advanced esophageal cancer. Fully covered SEMS (FCSEMS) (ALIMAXX-E, Alveolus Inc, Charlotte, NC, USA) offer the choice of removability if complications occur or maximum therapeutic benefit is achieved. To our knowledge, their use has not been studied in patients undergoing neoadjuvant therapy. The objectives of this study were the following: (i) to evaluate whether FCSEMS are useful in patients receiving neoadjuvant therapy; and (ii) to assess ease of removability and tissue reaction to FCSEMS. FCSEMS (ALIMAXX-E, Alveolus Inc) were deployed in consecutive patients with locally advanced esophageal cancer over a period of 14 months. All patients were referred for neoadjuvant chemoradiation therapy after stenting. Dysphagia scores were assessed at 0 month, 1 month, 3 months, and 6 months. Barium swallow and endoscopy were performed for new symptoms and follow-up. Eleven patients were treated with FCSEMS prior to neoadjuvant therapy (mean age 60.5 years, 55% white, 91% male). All but one stent were successfully placed. Strictures were located in the upper esophagus (n= 1), middle esophagus (n= 4), lower esophagus (n= 2), and gastroesophageal junction (n= 4). Dysphagia was significantly improved at 1 month (mean difference 3.12; 2.53-3.79 95% confidence interval [CI]), 3 months (mean difference 2.86, 2.19-3.53 95% CI), and 6 months (mean difference 2.56, 1.79-3.34 95% CI) compared with baseline. Three patients (27%) experienced chest pain or heartburn immediately following deployment. Only two patients ultimately underwent surgical resection. The others were diagnosed with metastatic disease prior to surgery, had disease progression in spite of neoadjuvant treatment, or died with the stent in place. Three patients developed delayed complications: recurrent dysphagia (n= 2) and tracheal-esophageal fistula (n= 1). Eight (73%) stents were subsequently removed, one because of complication (tracheal-esophageal fistula), one because of migration (recurrent dysphagia), one was incorrectly deployed, and five were felt to have satisfied their purpose. Stents remained in place for a mean duration of 100.36 days (range 0-105, median 84). Removal was characterized as very easy in all cases. Upon removal, ulcerations at the proximal or distal edge of stents were noted in six patients (75%), polyps in four (50%), and granulation in six (75%). One stent (13%) became embedded but was easily lifted from tissue. There were no perforations. Neoadjuvant treatment may have contributed to improvement in dysphagia scores. FCSEMS can be used to re-establish esophageal luminal patency in patients undergoing neoadjuvant therapy for locally advanced esophageal cancer, resulting in significant improvement in dysphagia over baseline. Tissue reaction to stents occurs but does not appear to impair removability.

Radiological balloon dilatation of post-treatment benign pharyngeal strictures

To assess the technical success, clinical outcomes and complications of radiologically guided balloon dilatation of benign strictures developing after treatment for head and neck cancer. Forty-six balloon dilatations were performed in 20 patients. All dilatations were performed over a guidewire. Technical success was 100 per cent. Fifteen of the 20 patients demonstrated clinical improvement in dysphagia scores. Improvement in dysphagia was temporary in all patients (median 102 days), with multiple dilatations usually required (total dilatations ranged from one to seven). Immediate complications were encountered in six of the 46 (13 per cent) dilatations and were all minor. Late complications occurred after two procedures (4 per cent): localised perforation (later complicated by secondary infection) and recurrence of a previous, small, pharyngo-cutaneous fistula. Radiologically guided balloon dilatation is straightforward to perform and is well tolerated, but there is a small risk of perforation. Relief of symptoms is likely to be temporary, requiring multiple subsequent dilatations. A minority of patients will obtain no symptomatic relief.

Comparison of Esomeprazole to Aerosolized, Swallowed Fluticasone for Eosinophilic Esophagitis

Both gastroesophageal reflux disease and allergy/atopy have been implicated in the pathogenesis of eosinophilic esophagitis (EoE). There are no prospective studies comparing treatment of EoE with acid suppression versus topical corticosteroids. To determine the outcome of adult eosinophilic esophagitis patients treated with esomeprazole versus topical fluticasone. Prospective randomized controlled trial. Academic medical center. Adults (18-80) diagnosed with EoE by symptoms of dysphagia and esophageal biopsies with >or=15 eosinophils/hpf. Subjects were randomized to esomeprazole (40 mg by mouth every morning) or aerosolized, swallowed fluticasone (440 mcg by mouth twice a day) for 8 weeks. Improvement in dysphagia (8-point scale), esophageal eosinophil infiltration before and after treatment, prevalence of GERD measured by validated questionnaire and baseline pH study. About 56% (14/25) had acid reflux by pH study. There was no difference between treatment groups in improvement in dysphagia scores [3/12 (25%) of the esomeprazole group versus 6/12 (50%) in the fluticasone group, P = 0.40]. Eosinophil infiltration decreased with treatment in both groups, and there was no difference in the amount of decrease between groups (P = 0.70). Small sample size, unexpectedly high drop-out rate. Gastroesophageal reflux disease is common in adult eosinophilic esophagitis patients. Dysphagia improves and esophageal eosinophilic infiltration decreases with either treatment. There was no difference in degree of improvement in dysphagia or eosinophil infiltration in patients treated with either topical fluticasone or oral esomeprazole. GERD may be important in the pathogenesis of adult EoE.

Comparison of double‐layered and covered Niti‐S stents for palliation of malignant dysphagia

Covered metal stents have been accepted as the treatment of choice for malignant dysphagia caused by esophageal and gastric cardia cancer, but stent migration is a major shortcoming. A double-layered Niti-S stent was therefore introduced to obviate this problem. We aimed to compare double-layered and covered Niti-S stents regarding safety, efficacy, and feasibility in the treatment of malignant dysphagia. Thirty-seven consecutive patients with malignant dysphagia due to inoperable esophageal or gastric cardia cancer were enrolled in a prospective, randomized study. The main outcomes were technical success, improvement in dysphagia score after stent insertion, and complications. Technical success was achieved at a similar rate in both groups (covered, 19/19 [100%]vs double layered, 16/17 [94%]). A week after stent insertion, the mean dysphagia score improved significantly in the covered and double-layered groups compared to baseline (from 2.95 +/- 0.52 and 2.88 +/- 0.33 to 1.00 +/- 0.47 and 1.06 +/- 0.24, respectively; P < 0.001). There was no difference in the survival of the patients in the two groups. The overall complications, including stent migration and tumor overgrowth, occurred more frequently with covered stents (11/19 [58%]) than double-layered stents (2/17 [12%]; P = 0.006). Newly-developed, self-expanding metal stents, (covered and double-layered Niti-S stents) were equally effective and feasible treatments for malignant dysphagia. However, double-layered Niti-S stents are preferable due to their favorable safety profile.

Quality of life assessment with different radiotherapy schedules in palliative management of advanced carcinoma esophagus: A prospective randomized study

Aim: To investigate the quality of life (QOL) of patients with advanced carcinoma esophagus treated with different palliative radiation schedules. Methods: Sixty-two consecutive patients with inoperable, non-metastatic carcinoma of the esophagus were randomly allocated to Arm-A (external radiotherapy 30 Gy/10 fractions + brachytherapy 12 Gy/two sessions), Arm-B (external radiotherapy 30 Gy /10 fractions) and Arm-C (external radiotherapy 20Gy /five fractions). The QOL was assessed using the European Organization for Research and Treatment of Cancer questionnaire at presentation, after treatment and at 3 months follow-up. Results: The mean QOL score improved, in arm-A from 38 to 52 after treatment and 56 at 3 months, in arm-B from 30 to 44 after treatment and 55 at 3 months and in arm-C from 24 to 40 after treatment but decreased to 37 at 3 months. Improvement in dysphagia scores at the first follow-up was 46.1% in arm-A, 25.0% in arm-B and 22.6% in arm-C. The difference was maintained at 3 months, with maximum improvement in arm-A (57.6%). No significant differences were found between the three arms with regard to complications and additional procedures needed for relief of dysphagia. Conclusion: In comparison with external radiotherapy alone, external radiotherapy with intraluminal brachytherapy has shown a trend toward better QOL and consistent dysphagia relief without significant difference in adverse effects.

A Randomized, Prospective Trial of Electrosurgical Incision Followed By Rabeprazole Versus Bougie Dilation Followed By Rabeprazole of Symptomatic Esophageal (Schatzki's) Rings

Background: Lower esophageal (Schatzki's) rings are a common cause of solid food dysphagia. Standard treatment involves passage of a single large bougie to disrupt the ring but symptoms recur in the majority of patients. Electrosurgical incision of the ring may provide a longer duration of symptom improvement as suggested in a retrospective trial. Acid suppression has been shown to decrease the recurrence rate of peptic strictures but there is no data on the treatment of Schatzki's rings. Aim: To compare the efficacy of bougie dilation to electrosurgical incision of symptomatic Schatzki's rings at one year follow up in the presence of rabeprazole treatment. Methods: Fifty consecutive patients referred for endoscopic evaluation of dysphagia found to have a schatzki's ring were randomized prior to EGD to Bougie dilation using a 52-54 French Maloney dilator or electrosurgical incision using a standard needle knife papillotome with 3-4 longitudinal incisions placed radially around the Schatzki's ring. All patients were placed on rabeprazole (20-40 mg/day) for the duration of the study. Analysis between groups was made using Wilcoxon rank-sum test for independent samples (dysphagia score) and t-test (GERD scores). Paired data were analyzed using Wilcoxon signed rank (dysphagia score) and paired t-test (GERD scores) within groups. A Kaplan-Meier survival curve measured symptom-free survival times. Results: Twenty-five patients each underwent bougie dilation and electrosurgical incision. All patients were followed for 12 months and final analysis performed. One episode of bleeding in the incision group was controlled with epinephrine injection. Symptom free survival times were significantly longer in the incision group (7.99 months) compared to bougie dilation group (5.86 months) (p = 0.03). The improvement in dysphagia scores was significant within each group comparing baseline to each time interval. The incision group experienced a significant improvement of dysphagia symptoms at one month compared to the bougie dilation group (p = 0.05). GERD scores improved significantly in both groups at all time intervals in the bougie dilation group and at all time intervals in the incision groups with the exception of 12 months. There was no significant difference in GERD scores between the groups. Conclusion: Electrosurgical incision of lower esophageal (Schazki's) rings is safe and offers longer symptom free survival compared to bougie dilation. The addition of rabeprazole offered significant improvement in GERD scores in both groups.

Cost-Effectiveness Decision Analyses Comparing Nd:YAG Laser, Brachytherapy and Self-Expandable Stent for Management of Unresectable Esophageal Cancer

Introduction: Different modalities for palliation of obstructive symptoms in patients with unresectable esophageal cancer are available. However, patient's survival is difficult to be estimated and therapeutic alternatives have significant differences in costs and effectiveness. Aim: To determine the cost-effectiveness of three strategies commonly used in the palliation of unresectable esophageal cancer: Self expandable stent (SES), brachytherapy and Nd:YAG laser. Methods: A Markov model comparing these three different initial approaches was designed. Probabilities and parameters for distribution were abstracted from randomized controlled trials and imputed to a 9-month time horizon. Effectiveness was measured in improvement in dysphagia score (0-4). Procedural and complication-related costs were obtained from US Medicare cost and a third-party payer perspective was adopted. A probabilistic cost-effectiveness analysis using Monte Carlo simulations was utilized to obtain a posterior joint distribution for costs and effectiveness. Average and incremental net health benefits, probabilities of cost-effectiveness and value of information were determined across a range of willingness to pay (WTP) values. Results: Laser has the lowest CE ratio, followed by brachytherapy at an incremental cost-effectiveness ratio (ICER) of $2947/unit of improvement in the dysphagia score. Brachytherapy has the lowest average CE ratios under the following scenarios: probability of re-obstruction with brachytherapy greater than 25%, probability of survival less than 67% and overall cost of brachytherapy less than $2620. In the probabilistic analysis, laser is the strategy with the highest probability of cost-effectiveness for WTP values lower than $3200. However, brachytherapy is the strategy with the highest probability of cost-effectiveness for all WTP yielding a positive net health benefit (threshold $4440). SES was a dominated strategy in our model. The uncertainty about the most CE strategy and the subsequent selection of suboptimal strategies in at least 4% of the time will lead to opportunity losses for the US health system ranging from $580,000 to $1.1 million dollars over the next 5 to 20 years. Conclusion: Conditional to the willingness to pay and current US Medicare costs, palliation of unresectable esophageal cancers with Nd:YAG laser and brachytherapy are the strategies with the highest probabilities of cost-effectiveness. Although a significant level of uncertainly exists for certain WTP values, brachytherapy is the preferred strategy given the amount of net health benefits it provides.

Laparoscopic Heller Myotomy With Toupet Fundoplication

This study was performed to assess the intermediate-term outcomes after laparoscopic Heller myotomy and posterior Toupet fundoplication in a single-surgeon series with the expectation of identifying patient and disease factors associated with poor outcomes. Retrospective analysis of prospectively collected data. Tertiary care teaching hospital with a comprehensive esophageal physiology laboratory. A total of 121 patients undergoing laparoscopic Heller myotomy with Toupet fundoplication (between December 1, 1996, and December 31, 2004) for achalasia were included. All patients had preoperative objective documentation of achalasia. A 5- to 6-cm-long myotomy was performed on the distal esophagus. The myotomy incision was extended 2 cm onto the stomach. A partial (270 degrees ) posterior Toupet fundoplication was performed as an antireflux mechanism in all patients. Data on preoperative and postoperative symptoms, manometry, and 24-hour ambulatory pH were prospectively collected. Symptoms were recorded with a standardized assessment tool. Patients with postoperative dysphagia scores of 2 or greater were considered treatment failure. Logistic regression modeling was performed to identify variables significant for poor outcomes. Preoperatively, 89 patients (73.6%) had severe dysphagia (dysphagia score, 3 or 4) and 32 patients (26.4%) had mild or moderate dysphagia (dysphagia score, 1 or 2). After a median follow-up period of 9 months, 102 patients (84.3%) (P<.001) had excellent relief of dysphagia (dysphagia score, 0 or 1). Eight additional patients (6.6%) demonstrated a significant (25%-75% [P=.01]) improvement in dysphagia scores. Only 11 patients (9.0%) had either no change or worse dysphagia. Postoperatively, all patients with manometry had a normal lower esophageal sphincter pressure (mean +/- SD, 14.7 +/- 6.6 mm Hg; P<.001) and good lower esophageal sphincter relaxation. Odds of failure were greatest for patients with severe preoperative dysphagia, male patients, and patients with classic amotile achalasia. Of the 60 patients having heartburnlike symptoms preoperatively (mean +/- SD score, 2.52 +/- 1.00), 19 (31.7%) continued to have similar symptoms after surgery. Sixteen (33.3%) of the 48 patients having postoperative pH studies demonstrated objective reflux (DeMeester score, >14.7). Five (31.2%) of these patients had symptoms of their reflux. Dysphagia improves in most patients after laparoscopic Heller myotomy with partial fundoplication. Patients with severe preoperative dysphagia, esophageal dilation, or amotile achalasia may have greater chances of a poor outcome.

Endoscopic Ablation of Intraepithelial Neoplasia in Barrett's Patients

Endoscopic Ablation of Intraepithelial Neoplasia in Barrett’s Patients Jelle Haringsma, Ilona Kerkhof, Jan Werner-Poley, Peter Siersema, Huug Tilanus, Ernst Kuipers Background: There is no generally accepted strategy for patients with intraepithelial neoplasia (IEN) in Barrett’s esophagus (BE). Esophagectomy is considered standard therapy for advanced cancer, and in many centers also for IEN. Surgical resection, however, carries considerable mortality and morbidity. Endoscopic ablation is developed as a minimally invasive organ-preserving therapy for IEN. There are limited data on outcome of such a strategy. We therefore aimed to determine the results of endoscopic ablation in patients referred for superficial neoplasia in BE. Methods: Prospective cohort study of all subjects with IEN referred to our tertiary center. 35 patients underwent endoscopic Mucosal Resection (EMR) of suspected BE lesions with a capped technique. In patients with high-grade neoplasia (Vienna class 4) endoscopic ablation was subsequently completed with Photodynamic Therapy (PDT) using 5-aminolevulinic acid 40 mg/kg at 633 nm 100J/ cm. Endoscopic biopsies were taken at 6 weeks, 3 mo and subsequently every 6 mo after PDT. Results: 56 patients (mean age 66 yrs, range 42-85) referred for superficial neoplasia in BE were evaluated. 7 patients with only low-grade IEN were followed. Primary surgical resection was performed in 10 of 49 patients based on endoscopic criteria, histological differentiation, and patient’s preference. 39 patients (80%) consented and were considered suitable for endoscopic ablation. Due to submucosal infiltration, poor differentiation and angio-invasion in the EMR specimen at histology, 5 were treated surgically, 4 were followed and 4 were treated otherwise. Endoscopic ablation was completed in 26. Of the latter group 21 patients had a sustained remission of severe neoplasia, 3 were subsequently treated surgically, 2 were followed. After a mean follow-up of 22 months, a total of 18/56 patients (32%) were operated upon. In 3 patients who had undergone EMR, no invasive cancer was found in the resection specimen. Operative mortality was 1/18 (5,5%). Three other patients died post-surgically: 1 from tumor recurrence, 2 from unrelated causes. Of 26 patients treated endoscopically, remission was sustained in 21 patients (81%). No major complications occurred. Conclusions: Endoscopic ablation can replace primary surgery in well-selected patients with severe intraepithelial neoplasia. Endoscopic ablation using EMR and PDT is safe and effective. Selection and endoscopic treatment of neoplasia in Barrett’s should be performed in expert centers. 495 A Randomized, Prospective Trial of Electrosurgical Incision Followed by Rabeprazole Versus Bougie Dilation Followed by Rabeprazole of Symptomatic Esophageal (Schatzki’s) Rings Jason C. Wills, Kristen Hilden, James DiSario, John C. Fang Background: Lower esophageal (Schatzki’s) rings are a common cause of solid food dysphagia. Standard treatment involves passage of a single large bougie to disrupt the ring but symptoms recur in the majority of patients. Electrosurgical incision of the ring may provide a longer duration of symptom improvement as suggested in a retrospective trial. Acid suppression has been shown to decrease the recurrence rate of peptic strictures but there is no data on the treatment of Schatzki’s rings. Aim: To compare the efficacy of bougie dilation to electrosurgical incision of symptomatic Schatzki’s rings at one year follow up in the presence of rabeprazole treatment. Methods: Forty-nine consecutive patients referred for endoscopic evaluation of dysphagia were randomized prior to EGD to Bougie dilation using a 52-54 French Maloney dilator or electrosurgical incision using a standard needle knife papillotome with 3-4 longitudinal incisions placed radially around the Schatzki’s ring. All patients completed validated GERD and dysphagia questionnaires at 0, 1, 3, 6, 9, and 12 months. All patients were placed on rabeprazole (20 mg/day) for the duration of the study. Analysis was made using Wilcoxon rank-sum (Mann-Whitney U) non-parametric test for independent samples (dysphagia score) and independent samples t-test (GERD scores and pH results). Results: Twenty-five patients underwent bougie dilation and 24 underwent electrosurgical incision. All patients had been followed for at least six months and an interim analysis was performed. There was one episode of bleeding in the incision group controlled with epinephrine injection. Dysphagia scores at 12 months decreased significantly in the incision group (median 5 / 0) compared with bougie group (median 7 / 3) (p Z 0.269). Both groups had significant improvement in GERD scores at 9 and 12 (p! 0.05). There was no difference in GERD improvement between the two groups at 12 (p Z 0.927). Conclusion: Electrosurgical incision of lower esophageal (Schatzki’s) rings is safe and offers similar improvement in dysphagia scores. Electrosurgical incision may offer more definitive relief of dysphagia (5/0) than bougie dilation (7/3) and require less frequent future interventions. Further follow up is needed. The addition of rabeprazole offered significant improvement in GERD scores in both groups.

A Randomized, Prospective Trial of Electrosurgical Incision Followed by Rabeprazole Versus Bougie Dilation Followed by Rabeprazole of Symptomatic Esophageal (Schatzki's) Rings

Background: Lower esophageal (Schatzki's) rings are a common cause of solid food dysphagia. Standard treatment involves passage of a single large bougie to disrupt the ring but symptoms recur in the majority of patients. Electrosurgical incision of the ring may provide a longer duration of symptom improvement as suggested in a retrospective trial. Acid suppression has been shown to decrease the recurrence rate of peptic strictures but there is no data on the treatment of Schatzki's rings. AIM: To compare the efficacy of bougie dilation to electrosurgical incision of symptomatic Schatzki's rings at one year follow up in the presence of rabeprazole treatment. Methods: Forty one consecutive patients referred for endoscopic evaluation of dysphagia were randomized prior to EGD to Bougie dilation using a 52-54 French Maloney dilator or electrosurgical incision using a standard needle knife papillotome with 3-4 longitudinal incisions placed radially around the Schatzki's ring. All patients completed validated GERD and dysphagia questionnaires at 0, 1, 3, 6, 9, and 12 months. All patients were placed on rabeprazole (20 mg/day) for the duration of the study. Analysis was made using Wilcoxon rank-sum (Mann-Whitney U) non-parametric test for independent samples (dysphagia score) and independent samples t-test (GERD scores and pH results). Results: Twenty-one patients underwent bougie dilation and 20 underwent electrosurgical incision. All patients had been followed for three months and an interim analysis was performed. There was one episode of bleeding in the incision group controlled with epinephrine injection. Dysphagia scores at 1 month decreased significantly in the incision group (median 5 -> 0) compared with bougie group (median 7 -> 3) (p=0.0207). At 3 months there was a trend toward improvement in dysphagia scores, median 5 -> 0 in incision group, median 7 -> 2.5 in the bougie group (p=0.2032). Both groups had significant improvement in GERD scores at 1 and 3 months (p< 0.05). There was no difference in GERD improvement between the two groups at 1 and 3 months ( p=0.6047 and 0.2458). Conclusion: Electrosurgical incision of lower esophageal (Schatzki's) rings is safe and offers improved symptom relief at 1 and 3 months versus bougie dilation but longer follow is needed. Symptoms of GERD do not differ between treatment groups. The addition of rabeprazole offers significant improvement in GERD scores in both groups at both 1 and 3 months.