Persistent Dysplasia Research Articles

A208 ENDOSCOPIC SUBMUCOSAL DISSECTION (ESD) FOR BARRETT’S NEOPLASIA: CLINICAL OUTCOMES AND MID-TERM FOLLOW-UP AT A CANADIAN TERTIARY REFERRAL CENTER

Abstract Background Endoscopic submucosal dissection (ESD) is an established technique for resecting early gastrointestinal neoplastic lesions. However, for Barrett’s neoplasia treatment, piecemeal EMR has been the standard approach, leaving the efficacy of ESD for Barrett’s neoplasia unclear. Aims To assess the outcomes of Barrett’s neoplasia treated with ESD at a tertiary center in Canada. Methods This is a single center, retrospective study. All patients aged over 18 who underwent ESD for Barrett’s neoplasia at St. Michael’s Hospital between December 2017 and August 2023 were included. Primary outcomes were En-bloc, R0, curative resection, and recurrence rates, while secondary outcomes focused on the adverse event rate. Results Of the 72 patients studied (mean age 67.7 years; 90% male), 31.9% (23/72) were SSBE and 68.1% (49/72) were LSBE. The mean±SD lesion size was 4.5±3.4 cm, with circumferential occupancy at 53.4±23.9 %. Paris classifications were as follows: 0-Is: 8 (11.1%), 0-IIa: 26 (36.1%), 0-IIb: 9 (12.5%), 0-IIc: 6 (8.3%), 0-IIa+IIc: 13 (18.6%), 0-IIa+Is: 10 (13.9%). The mean operation time stood at 144.4 (75.3) minutes. Adverse events comprised deep mural injury (4.1%) and delayed bleeding (2.8%). Pathology findings showed high-grade dysplasia in 6.9% and adenocarcinoma in 93.1%, further differentiated as: well-differentiated (55%), moderately differentiated (33%), and poorly differentiated (12%). The invasion depth was intramucosal in 76%, SM1 in 6%, and SM2-SM3 in 18%. Lympho-vascular invasion was present in 22%. En-bloc, R0, and curative resection rates were 96% (69/72), 82% (59/72), and 64% (46/72), respectively. Of the curative resection patients, 42 have completed follow-up EGD, with 11.9% (5/42) showing persistent dysplasia at first follow-up. These were treated by either EMR (4 cases) or ESD (1 case), leading to a 100% (42/42) complete remission of dysplasia (CRD) rate with median follow-up time of 127 (68-190) days. After achieving CRD, local recurrence was found in 2.4% (1/42) with a median follow-up time of 289 (136-524) days. This recurrence post-CRD was successfully treated with EMR, regaining CRD. Conclusions Our study showcases the Canadian experience of using ESD for Barrett’s neoplasia at a large single tertiary referral center. Given the challenging demarcation lines in Barrett’s neoplasia and the frequent presence of metachronous lesions, even with curative resection, 11.9% showed persistent lesions during the first follow-up. However, these lesions were treatable endoscopically, with 100% eventually achieving CRD. Although there was a 2.4% recurrence rate post-CRD, this too could be managed endoscopically. Overall, the mid-term outcomes of treating Barrett’s neoplasia with ESD are promising. Funding Agencies None

Watchful waiting for the undisplaced hip dysplasia when undergoing contralateral hip reconstruction.

Patients undergoing surgical reduction of the dislocated hip secondary to developmental dysplasia may have a contralateral undisplaced dysplastic hip. This study aimed to compare the observation of the contralateral undisplaced dysplastic hip with the treatment by acetabuloplasty in terms of persistent dysplasia to determine the need for bilateral surgery. Acetabular dysplasia was defined by an acetabular index (AI) of more than 30 degrees plus a center edge angle (CEA) of less than 20 degrees. A surgical database was queried retrospectively for a cohort between 2008 and 2016. Inclusion criteria were aged between 1 and 6years, unilateral developmental dysplasia (international hip dysplasia institute grade 1) with contralateral dislocation, no previous treatment and a minimum follow-up of 1 year. Fifty-seven patients were included, 40 in the observation group and 17 in the acetabuloplasty group. The mean age (interquartile range) was 20 (17-23) months, and the mean follow-up was 42 (22-62) months. The baseline values were similar for both groups. At the final follow-up, no hip had dysplasia, as specified a priori in either group, but the final AI and CEA were corrected more in the acetabuloplasty group (p < 0.001). Based on the adjusted analysis, both acetabuloplasty and follow-up without treatment were associated with improved acetabular coverage. Watchful expectancy of undisplaced hip dysplasia presenting in patients undergoing contralateral hip reconstruction during years of acetabular growth is safe as the risk of persistent dysplasia and additional surgery is low. III.

MRI Predictors of Residual Dysplasia in Developmental Dysplasia of the Hip Following Open and Closed Reduction.

Following open or closed reduction for children with developmental dysplasia of the hip, there remains a significant risk of residual acetabular dysplasia which can compromise the long-term health of the hip joint. The purpose of this study was to use postoperative in-spica magnetic resonance imaging (MRI) data to determine factors predictive of residual acetabular dysplasia at short-term follow-up. We retrospectively reviewed 63 hips in 48 patients which underwent closed or open reduction and spica casting for developmental dysplasia of the hip. MRI performed in-spica at ∼3-week follow-up were used to assess 11 validated metrics and 2 subjective factors. Acetabular index (AI) was measured on anteroposterior pelvic radiographs at 2-year postoperative follow-up. Binary logistic regression was then used to identify variables predictive of residual dysplasia, defined as an AI greater than the 90th percentile for age based on historic normative data. Average age at surgical reduction was 9.3±3.2 months. 58.7% (37/63) of reductions were open. A total of 43 (68.3%) hips demonstrated residual acetabular dysplasia at 2 years postoperatively based on normative values. In those with persistent dysplasia, patients were on average older at the time of reduction (10.0 mo±3.2 vs. 8.0 mo±2.8, P=0.010) and more likely female (88.4% vs. 60.0%, P=0.010). Patients with residual dysplasia were more likely to have mild subluxation on postoperative MRI (40.0% vs. 10.5%, P=0.022). Hips with a cartilaginous acetabular index (CAI) of >23 degrees were 7.6 times more likely to develop residual dysplasia. Type of reduction (ie, closed vs. open) did not appear to influence the rate of residual dysplasia (P=0.682). In this series, the rate of residual dysplasia after surgical reduction was higher than most previous reports, with no appreciable difference between closed and open reductions. Older age, female sex, and a higher CAI were associated with a greater risk of persistent radiographic dysplasia. In particular, hips with a CAI >23 degrees were 7.6 times more likely to be dysplastic at 2-year follow-up. Level III.

Long-Term Outcome of Gastric Mild-Moderate Dysplasia: A Real-World Clinical Experience

The natural course of gastric mild-moderate dysplasia in a country with high incidence of gastric cancer (GC) is relatively unknown. We aimed to determine the long-term cumulative incidence of and risk factors for advanced neoplasia in patients with gastric dysplasia. This was a single-center observational study including all consecutive patients diagnosed with gastric mild-moderate dysplasia between 2000 and 2017. Follow-up data were collected until December 2019. We determined the cumulative incidence of advanced neoplasia and identified risk factors with Cox regression. A total of 3489 consecutive participants were followed for a median of 4.19 years from initial mild-moderate dysplasia diagnosis. The median surveillance interval between index endoscopy and next follow-up endoscopy was 1.08 years, and more than half of patients had at least 3 surveillance gastroscopies. During the study period, the majority of participants did not show disease progression, either with dysplasia not detected (51.4%) or with persistent dysplasia (46.1%). There were 88 (2.9%) patients (5.13 per 1000 patient-years) who progressed to advanced neoplasia within a median of 4.3 years. The annual incidence of advanced neoplasia and GC were 0.43% and 0.26%, respectively, within 5 years of mild-moderate dysplasia diagnosis. Increasing age, male sex, moderate dysplasia, dysplasia detected in fundus or cardia at index endoscopy, and persistent Helicobacter pylori infection during follow-up were independent risk factors for developing advanced neoplasia. Even in a country with high incidence of GC, the majority of patients with gastric mild-moderate dysplasia did not experience disease progression in the long term. Intensified surveillance during the first 5 years after mild-moderate dysplasia detection is suggested.

A Comparative Study between Nissen's Fundoplication with or without Endoscopic Mucosal Resection in the Treatment of Barrett’s Oesophagus: a Meta-Analysis

Abstract Background It is already known that Barrett’s esophagus (BE) is a premalignant condition in which the normal squamous epithelium of the distal esophagus is replaced by columnar epithelium (intestinal metaplasia or gastric metaplasia) due to GERD. Most observers believe that there is a progression from intestinal metaplasia to low-grade dysplasia (LGD) to highgrade dysplasia (HGD) to cancer. The relative risk of developing esophageal adenocarcinoma in patients with BE appears to be 30-fold higher. Conventional therapies include medical treatment (profound acid inhibition), endoscopic treatment (like endoscopic mucosal resection) and surgical treatment (fundoplication). Methodology Types of studies: Published studies about the efficacy of Nissen’s Fundoplication with or without Endoscopic Mucosal Resection in the treatment of Barrett’s Oesophagus (carried out in the period between 2015 – 2020), types of participants Patients with clinically proven Barrett’s Oesophagus diagnosed by endoscopy and biopsy, types of interventions Nissen’s Fundoplication (Open or Laparoscopic) with or without Endoscopic Mucosal Resection, types of outcome measures Outcome of treatment in the form of Complete Remission of Columnar Metaplasia of the oesophageal mucosa or regression in recurrence rate as proved by follow-up endoscopy. Results The strategy of endoscopic therapy for Barrett’s metaplasia, dysplasia and/or intramucosal cancer along with fundoplication results in similar durability and recurrence rates when compared to patients being managed with PPIs following endoscopic therapy. However, fundoplication along with endoscopic therapy is superior to either of them alone in preventing further progression of disease and the development of cancer, particularly in refractory patients. Fundoplication is an important strategy along with endoscopic therapy for Barrett’s to achieve and maintain CR-IM, and to facilitate the eradication of persistent dysplasia. Conclusion Endoscopic mucosal resection after Nissen's Fundoplication is a safe modality, with high rate of success in complete eradication of BE in symptomatic GERD patients, especially those with severe anatomical impairment in distal esophageal segment. As a concurrent procedure, endoscopic procedures may be beneficial in the terms of reducing the early recurrence rates, which seems to be important issue during the management of BE. By doing synchronous endoscopic procedures and fundoplication, one might observe a true anatomy of esophagogastric junction in its entirety and might be able to truly observe the distal extent of columnar esophagus.

The Development of Leg Length Difference and Influence on Persistent Dysplasia in Patients with Developmental Dysplasia of the Hip.

Leg-length difference (LLD) is common in patients with developmental dysplasia of the hip (DDH). LLD of > 1cm at skeletal maturity is reported in > 40% of patients, with the majority related to ipsilateral overgrowth. A longer DDH leg might lead to excessive mechanical loading at the acetabular margin, resulting in compromised acetabular development. We hypothesised that the LLD would negatively influence acetabular development. If so, it would be advantageous to identify such patients early in the course of follow-up, and address this if necessary. A retrospective study was conducted on a consecutive series of DDH patients managed surgically at the Royal National Orthopaedic Hospital, Stanmore, United Kingdom. We included patients with adequate long-leg radiographs at the age of 4-8years (early-FU) and skeletal maturity (final-FU). Bilateral cases and those who underwent surgical procedures for hip dysplasia during the follow-up period were excluded. Measurements including leg length and centre-edge-angle (CE-angle) were obtained at the 2 time points. Twenty-seven patients were included, mean age at early-FU 5.7 (± 0.9)years, and 13.9 (± 1.0)years at final-FU. Mean LLD at early-FU was 9.5 (± 7.6)mm and 10.9 (± 9.4)mm at final-FU, p = 0.337. Correlation between early- and final-FU LLD was 0.68 (p < 0.001). The mean CE-angle at early follow-up was 14.6° (± 9.8), this improved to 23.2° (± 8.2) at skeletal maturity (p = 0.003, paired samples t-test). Linear regression analysis showed a non-significant trend towards less CE-angle improvement in patients with more initial residual dysplasia and more initial LLD. Most leg-length differences can be identified early in the follow-up period, nevertheless, considerable individual changes in LLD are observed on continued follow-up. Furthermore, a trend was observed towards impaired acetabular improvement in patients with more LLD. These findings justify careful clinical and radiological monitoring of LLD from an early stage in the follow-up period. The online version contains supplementary material available at 10.1007/s43465-021-00492-5.

Can we ameliorate the safety of intraductal radiofrequency ablation for persistent dysplasia after endoscopic ampullectomy ?

Can we ameliorate the safety of intraductal radiofrequency ablation for persistent dysplasia after endoscopic ampullectomy ?

Diagnostic Approach To Oligomonocytic Chronic Myelomonocytic Leukemia

Abstract Casestudy: Pathologic diagnosis of chronic myelomonocytic leukemia (CMML) is typically straightforward with the majority of patients presenting with persistent monocytosis (&amp;gt;1x109/L, &amp;gt;=10%) and bone marrow dysplasia. The diagnosis may be challenging in patients with unusual features such as lack pf peripheral blood monocytosis and non-diagnostic bone marrow morphology. In this abstract, we present a 67-year-old female with a 5-year history of anemia of unclear etiology. At the time of initial presentation, the laboratory work-up of normocytic anemia was non- contributory, the bone marrow was reported as normocellular with maturing trilineage hematopoiesis and no significant dysplasia. Over the course of the disease, the peripheral blood monocyte count fluctuated from 11% to 18% with absolute monocyte count ranging from 0.4 to 0.7x109/L. The most recent bone marrow was markedly hypercellular with increased trilineage hematopoiesis with left shift, dysgranulopoiesis and dysmegakaryopoiesis. Blasts (including promonocytes) constituted 10% of the differential count and were immunophenotypically abnormal with uniform expression of CD117, dim to negative CD13, and partial CD15. Monocytes were elevated at 12% and were strongly positive for CD64 and partially for CD14. They were negative for CD16 consistent with classical monocytes, and showed partial loss of CD13. The karyotype was normal. Molecular testing revealed TET2, RELN and SRSF2 mutations at high allelic frequencies. This case illustrates a value of flow cytometric immunophenotyping and molecular genetic studies in diagnosing challenging cases of CMML. While the patient’s absolute monocyte count remained below the diagnostic threshold of 1x109/L throughout the course of the disease, peripheral blood and bone marrow monocytes showed skewed classical immunophenotype, immunophenotypic abnormalities of myeloid series and high allelic frequency mutations. These findings should raise a differential diagnosis of oligomonocytic CMML, even when morphologic abnormalities and monocyte count threshold are not diagnostic.

Efficacy of Cryotherapy as a Primary Endoscopic Ablation Modality for Dysplastic Barrett's Esophagus and Early Esophageal Neoplasia: A Systematic Review and Meta-Analysis.

Introduction:Cryotherapy is a cold-based ablative therapy used primarily as second line therapy in patients with Barrett’s esophagus (BE) who have persistent dysplasia after undergoing endoscopic treatment with radiofrequency ablation (RFA). Few studies have described the use of cryotherapy as a primary treatment modality for dysplastic or neoplastic BE.Aim:To evaluate the efficacy of cryotherapy as primary treatment of dysplastic and/or neoplastic BE by conducting a systemic review and meta-analysis.Methods:A systematic search of Medline, Embase, and Web of Science was performed from January 2000 through March 2020. Articles included were observational studies and clinical trials which included patients who had biopsy confirmed dysplastic or neoplastic BE (i.e., high grade dysplasia (HGD), low grade dysplasia (LGD) or intramucosal adenocarcinoma (ImCA)), underwent ≥1 session of cryotherapy, and had a follow-up endoscopy. Primary outcomes were pooled proportions of patients achieving complete eradication of dysplasia (CE-D) and/or intestinal metaplasia (CE-IM) by using a random effects model.Results:Fourteen studies making up 405 patients with follow-up ranging from 3-54 months were included. In 13 studies, a total of 321/405 patients achieved CE-D with a pooled proportion of 84.8% (95% confidence interval [CI] 72.2-94.4), with substantial heterogeneity (I2 = 88.3%). In 13 studies, a total of 321/405 patients achieved CE-D with a pooled proportion of 84.8% (95% confidence interval [CI] 72.2-94.4), with substantial heterogeneity (I2 = 88.3%). Subgroup analysis of only high-quality studies revealed a pooled proportion of CE-D 91.3% (95% CI, 83.0-97.4, I2 = 69.5%) and pooled proportion of CE-IM of 71.6% (95% CI, 59.0-82.9, I2 = 80.9%). Adverse events were reported in 12.2% patients.Conclusion:Cryotherapy is a safe and effective primary therapy for dysplastic/early neoplastic BE. CE-D and CE-IM rates are comparable to those for other ablation modalities, including RFA. Cryotherapy should be considered for primary therapy of dysplastic BE and early esophageal neoplasia.

Abduction treatment in stable hip dysplasia does not alter the acetabular growth: results of a randomized clinical trial

Background The effect of bracing over natural history of stable dysplastic hips is not well known. This multicenter randomized trial aimed at objectifying the effect of abduction treatment versus active surveillance in infants of 3 to 4 months of age. Methods Patients were randomized to either Pavlik harness or active surveillance group. Ultrasound was repeated at 6 and 12 weeks post randomization. The primary outcome was the degree of dysplasia using the Graf α-angle at 6 months of age. The measurement of the acetabular index (AI) on plain pelvis X-rays was used to identify persistent dysplasia after 9 months and walking age (after 18 months). Findings The Pavlik harness group (n = 55) and active surveillance group (n = 49) were comparable for predictors of outcome. At 12 weeks follow-up the mean α-angle was 60.5° ± 3.8° in the Pavlik harness group and 60.0° ± 5.6° in the active surveillance group. (p = 0.30). Analysis of secondary outcomes (standard of care) showed no treatment differences for acetabular index at age 10 months (p = 0.82) and walking age (p = 0.35). Interpretation Pavlik harness treatment of stable but sonographic dysplastic hips has no effect on acetabular development. Eighty percent of the patients will have a normal development of the hip after twelve weeks. Therefore, we recommend observation rather than treatment for stable dysplastic hips.

935 Salvage Hybrid APC After Failed Radiofrequency Ablation and Cryotherapy for Barrett’s Esophagus

INTRODUCTION: The frequency of Barrett’s esophagus (BE) has increased by a factor of more than 7 during the past four decades in the United States. It has been estimated that 5.6 percent of adults in the United States have Barrett's esophagus, although the large majority of cases go unrecognized. Endoscopic resection of visible lesions, followed by ablation of the rest of the BE epithelium is the current standard of care for management of BE with confirmed dysplasia and IMC. Today, the most readily use treatment for Barret’s esophagus is RFA and APC. None of the current methods are able to guarantee a complete ablation success of 100 %. Cryotherapy has become a salvage technique for patient that have failed RFA. There is limited data available to determine the efficacy and safety of this technique. For patients who failed RFA and Cryotherapy, there are limited options available. The aim of this study is to assess the efficacy and safety of hybrid APC in patients with BE dysplasia who failed RFA and cryotherapy.Hybrid APC can be an effective alternative adjunctive salvage tool to RFA and cryotherapy for patients in whom both of these techniques have failed. METHODS: This is a single center, retrospective cohort study at a tertiary medical center between 2010 and 2019 in patients with BE low-grade dysplasia (LGD) and high grade dysplasia (HGD) who failed RFA and cryotherapy treatment. Six patients with an average age of 63, and five out of six are males (84%) and five have persistent LGD (84%). Response was determined by complete eradication (CE). Six patients with persistent dysplasia and with incomplete response to RFA and cryotherapy were offered hybrid APC. The primary endpoint was CE after hybrid APC. RESULTS: A total of 6 patients underwent RFA and Cryotherapy for BE dysplasia. After an average of 4.5 RFA sessions and 2.7 Cryotherapy session none of the patient were able to reach CE. 5 patients with BE with LGD and 1 with HGD were offered H-APC after failure of reaching CE (average of 2.3 H-APC treatment). CE was reached in 100% of the patients who underwent H-APC. 6 months endoscopic surveillance has not shown any recurrence of BE or dysplasia. CONCLUSION: Patient with refractory dysplasia or recurrent dysplasia after failed eradication of salvage cryotherapy and radiofrequency ablation were offered hybrid APC. The data demonstrate a complete eradication in those patients who failed treatment with RFA and cryotherapy. Furthermore, there were no alternative outcome reported as of to date.

Efficacy of cryotherapy as first line therapy in patients with Barrett's neoplasia: a systematic review and pooled analysis.

Cryotherapy has been used as salvage therapy; however, its efficacy as first line treatment in patients with Barrett's esophagus (BE) neoplasia has not been well studied. The aim of this paper was to perform a systematic review to look at the efficacy of cryotherapy as the primary treatment of BE. An electronic database search was performed (PubMed, Embase, Cochrane, and Google Scholar) to search for studies with cryotherapy as the initial primary modality of ablation in patients with BE neoplasia. Studies that included patients with other prior forms of therapy were excluded. The primary outcomes were the pooled rates of complete eradication of intestinal metaplasia (CE-IM) and CE of neoplasia (CE-N). Secondary outcomes were recurrence rates of neoplasia and intestinal metaplasia (IM) and adverse events. The statistical software OpenMetaAnalyst was used for analysis with pooled estimates reported as proportions (%) with 95% confidence intervals (CI) with heterogeneity (I2) among studies. The search revealed 6 eligible studies with a total of 282 patients (91.5% male, average age 65.3 years) with 459 person years of follow-up. 69.35% [95% CI (52.1%-86.5%)] of patients achieved CE-IM and 97.9% (95% CI: 95.5%-100%) had CE-N. 7.3% of patients had persistent dysplasia with 4% progressing to cancer. The recurrence rate of neoplasia was 10.4 and that of IM was 19.1 per 100 patient years of follow-up. The overall rate of stricture formation was 4.9%. There are scarce data on the use of cryotherapy as the primary modality for the treatment of BE dysplasia. The published data demonstrate efficacy rates of 69% and 98% for complete eradication of metaplasia and neoplasia, respectively. These results need to be assessed in prospective, comparative trials with other forms of therapy.

Pavlik Harness initiation on Barlow positive hips: Can we wait?

We investigated if infants with a Barlow positive hip(s) have natural hip stabilization and can thus avoid Pavlik Harness (PH) treatment. We conducted a chart review for infants who presented within two weeks of life, had a Barlow positive hip, and were deferred treatment. Of the thirty infants, eighteen were treated with PH at 4–6 weeks or 12 weeks due to persistent dysplasia. Twelve infants avoided PH entirely. There were zero cases of PH failure. Parents can be counseled that deferring treatment until at least 4–6 weeks of age might avoid treatment altogether without an increased risk of harness failure.

FA02.05: PROGRESSION RATE OF BARRETT’S ESOPHAGUS FROM NATIONAL REGISTRY OF EXPERT CENTERS IS MUCH GREATER THAN ANTICIPATED FROM POPULATION STUDIES

Abstract Background Barrett's Esophagus (BE) is well established as the main pathological precursor for esophageal adenocarcinoma (EAC). Progression to high grade dysplasia (HGD) or EAC varies widely between population based studies and specialized BE registries from high volume centers. No such data existed from the Republic of Ireland until 2011 when a multicenter registry was established involving three centers to more accurately determine the risk of progression to EAC in the Irish population. Methods A detailed clinical, endoscopic and pathological database includes 3397 patients from January 2008 to July 2017, with BE defined by the presence of specialized intestinal metaplasia (SIM). A prospective web based database was used to gather information from three designated esophageal centers with initial and follow up data abstracted by a data manager and overseen by a project manager. Results 325 were excluded following a diagnosis of HGD or EAC at index biopsy, or being a tertiary referral, leaving 3072 with a median age of 61 and a 2.1:1 male to female ratio and a median follow up of 3 years, and 5024 person years. 127 (4%) cases progressed to HGD/EAC, 65 after one year of follow up. 55 (2%) developed EAC were identified, 30 of those within one year. The overall incidence HGD/EAC was 2.53% per year, 1.3% if the first year is excluded. The risk of progression to EAC alone was 1.09% per year, 0.5% excluding the first year. Low grade dysplasia (LGD) on index biopsy was associated with a progression rate of 11.7% per year, 4.2% with the first year excluded. Conclusion With strict data entry and pathologic quality assurance, progression rates for non-dysplastic BE was several fold higher than population studies, highlighting caution in abstracting from population data. True LGD, as evidenced in a recent report by Kestens et al.1 represent high risk disease, with most of the risk evident within the first year. Reference: 1. Kestens C, Offerhaus G, van Baal J, Siersema PD. Patients wtih Barrett's esophagus and persistent low-grade dysplasia have an increased risk for high- grade dysplasia and cancer. Clin Gastroenterol Hepatol. 2016;14:956–962 Disclosure All authors have declared no conflicts of interest.

Cryotherapy and Radiofrequency Ablation for Eradication of Barrett's Esophagus with Dysplasia or Intramucosal Cancer.

Endoscopic ablation therapy has become the mainstay of treatment of Barrett's associated dysplasia and intramucosal cancer (IMC). The widely available techniques for ablation are radiofrequency ablation (RFA) and cryotherapy. Our aim was to compare eradication rates of metaplasia and dysplasia with both these modalities. Retrospective review of prospectively collected database of patients who underwent endoscopic therapy for Barrett's dysplasia or IMC from 2006 to 2011 was performed. Demographic features, comorbidities, and endoscopic data including length of Barrett's segment, hiatal hernia size, interventions during the endoscopy and histological results were reviewed. Among 154 patients included, 73 patients were in the RFA and 81 patients were in the cryotherapy group. There was complete eradication of intestinal metaplasia (CE-IM) in 81 (52.6%), complete eradication of dysplasia (CE-D) in 133 (86.4%), and persistent dysplasia or cancer in 19 patients (12.3%). Compared to RFA, cryotherapy patients were found to be older and less likely to have undergone endoscopic mucosal resection. On multivariate analysis, patients who underwent RFA had a threefold higher odds of having CE-IM than those who underwent cryotherapy (odds ratio [OR] 2.9, 95% confidence interval [CI] 1.4-6.0, p = 0.004), but CE-D were similar between the two groups (OR 1.7, 95% CI 0.66-4.3, p = 0.28). Endoscopic therapy is highly effective in eradication of Barrett's associated neoplasia. Patients who underwent cryotherapy were equally likely to achieve CE-D but not CE-IM than patients who underwent RFA. Patient characteristics and preferences may effect choice of treatment selection and outcomes.

Cryotherapy in Barrettʼs Esophagus Refractory to Radiofrequency Ablation: 2017 Presidential Poster Award

Introduction: Endoscopic ablative therapy is recommended in patients with nonnodular Barrett's esophagus (BE)-related dysplasia/neoplasia. Radiofrequency ablation (RFA) is effective, but a proportion of patients will have persistent dysplasia and/or intestinal metaplasia (IM) despite ablative therapy. Although cryotherapy ablation is often performed in this setting, its efficacy is not well defined. We aimed to assess the efficacy of salvage cryotherapy ablation in patients with RFA-refractory BE. Methods: We analyzed prospectively collected data on patients with BE-related dysplasia/neoplasia undergoing RFA at a tertiary referral center from 2008-2016. Before receiving RFA, all visible esophageal nodularity was removed by endoscopic mucosal resection (EMR). Patients with BE-related low-grade dysplasia (LGD), high-grade dysplasia (HGD), or intramucosal carcinoma (IMC) underwent RFA performed by 1 of 2 BE experts every 3 months until eradication of BE or progression to cancer. Biopsies were obtained prior to each RFA session to assess for complete eradication of dysplasia (CE-D) and complete eradication of intestinal metaplasia (CE-IM). At each endoscopist's discretion, patients with persistent dysplasia or IM were offered liquid nitrogen based cryotherapy ablation. Patients with a minimum 3 RFA sessions followed by a minimum 2 cryotherapy sessions with subsequent follow-up endoscopy with biopsies were included for further review. Results: 23 patients had persistent dysplasia or IM following a minimum of 3 RFA sessions and received cryotherapy ablation. Their baseline characteristics are shown in Table 1. The majority of patients had BE-HGD (61%) and BE-LGD (35%) at baseline, with a median maximum BE length of 9 cm. After a median 4 RFA sessions, 15/23 (65%) had persistent dysplasia and 8/23 (35%) had persistent IM. The overall median BE length decreased to 5 cm. Following a median 3 cryotherapy sessions, 6/15 (40%) achieved CE-D and 3/23 (13%) achieved CE-IM. The overall median BE length decreased to 3 cm. Overall, 13/23 (57%) experienced an improvement in histologic grade and 15/23 (65%) in BE length after salvage cryotherapy ablation (Table 2). However, during this time period, 3/23 (13%) patients experienced histologic progression (2 IMC, 1 HGD).Table: Table. Baseline CharacteristicsTable: Table. Outcomes of salvage cryotherapyConclusion: In our experience with RFA-refractory BE, salvage cryotherapy ablation achieves CE-D in less than half of patients and CE-IM in a minority of patients. Progression in this group is a significant concern. Ongoing efforts are necessary to determine the optimal clinical strategy in this group of patients refractory to traditional treatment.

A prospective study of the natural outcome and treatment indications of infant GrafIIa hip dysplasia

Objective To observe the natural outcomes of Graf typeⅡa hip dysplasia aged 6 weeks to 3 months, and to explore the indications of treatment. Methods A prospective study was conducted to collect children aged from 6 to 12 weeks with Graf typeⅡa dysplasia (50°≤α angle<60°) but clinically stable hips according to the Early Screening of Developmental Dysplasia of the Hip in Tianjin project from July 2012 to July 2014. Those hips with history of treatment or neuromuscular disorders were excluded. All infants had no treatment initially following with ultrasound surveillance each 2 weeks and radiograph evaluation each at 3, 4.5 and 6 months of age. Patients received Pavlik harness or abduction brace treatment if hip dysplasia turned to be type GrafⅡc or worse, or clinical unstable before 6 months; also if hip dysplasia was persistent in radiograph at 6 months. All infants were routinely followed up at 12 and 24 months of age to detect the late cases. The difference of initial α angle, hip abduction, acetabulum index and acetabulum margin morphology (sharp, round or defect) in the pelvic radiograph at 3 month were compared between the treated and untreated groups. Results A total of 238 children (285 hips) were enrolled in the present study, of which there were 25 males and 213 females, 193 left and 92 right hips. The average age was 9 weeks (range 6 to 12 weeks). No hip turned to be typeⅡc or worse, or clinically unstable. One hundred patients (120 hips) received treatment for persistent dysplasia at 6 months. There had statistically significant difference in initial α angle between the treated and untreated groups (respectively 54.5°±3.3° and 55.6°±2.9°, t=-2.749, P=0.004). In the treated group, there were 47 hips (39.2%, 47/120) with limited abduction initially, and 52 hips (43.3%, 52/120) with poor acetabular morphology at 3 months. The differences were statistically significant comparing with the untreated group (χ2=4.010, P=0.045; χ2=14.143, P=0.000). Logistic multivariate regression analysis showed that patients with GrafⅡa-hips (OR=2.908) and poor acetabular morphology hips (OR=2.822) were more likely to receive treatment. Thirty-eight patients (47 hips) received treatment among GrafⅡa+ hips (α angle ≥55°), of which 21 hips (44.7%, 21/47) had limited abduction and 31 hips (66.0%, 31/47) poor acetabular morphology. The differences were statistically significant comparing with untreated cases (χ2=12.073, P=0.001; χ2=35.879, P=0.000). Logistic multivariate regression analysis showed that Graf Ⅱa+ hips with limited hip abduction (OR=4.145) and poor acetabular morphology (OR=10.117) were more likely to receive treatment. Conclusion GrafⅡa dysplasia with clinically stable hips should be treated if α angle <55° at 6 weeks or if α angle ≥55° with limited hip abduction or poor acetabular morphology (round or defect) at 3 months. Key words: Hip dislocation, congenital; Infant; Ultrasonography; Prospective studies

Comparison of two different medial reference points for measurements of the acetabular index

Introduction: Acetabular index (AI) is a commonly used quantitative measurement of acetabular inclination in plain radiographs. Repeated measurements of this index are used to determine dysplasia in children and for decision making about surgical management. Persistent acetabular dysplasia may be an indication for performing an acetabuloplasty. AI is commonly measured between the Hilgenreiner’s line (line that connects both triradiate cartilages) and the line joining lateral most ossified margin of the acetabulum and triradiate cartilage. Two different methods for measurement of AI with two different medial reference points at the triradiate cartilage have appeared in the literature. Aim: The specific aim of the study was to investigate the difference between AI measurements with two different methods and report on intraobserver and interobserver reliability of both the methods. Materials and Methods: Ninety-eight children with developmental dysplasia of the hip (DDH) (treated and untreated), younger than 9 years, were included in the study. Anteroposterior radiographs of the pelvis having acceptable pelvic rotation and pelvic tilt were included in the study. AI was measured using two different reference points for the affected and normal sides. AI was measured twice at 1-month interval by two investigators. The difference between the two measurement techniques was compared by the paired “t” test. Pearson’s correlation coefficient was calculated to test associations between the two measurement techniques. Results: The reproducibility of measurements of both the techniques was found satisfactory [intraclass correlation (ICC)-0.90 and 0.87]. Statistically significant difference (P value < 0.001) (5.7° for affected and 5.3° for normal side) between the indices measured by two techniques was noted. This difference was noted for all age groups. Significant positive correlations between both the techniques were noted in normal as well as dysplastic hips. Conclusion: Acetabular indices measured with two different medial points gave significantly different values. All subsequent assessment should be consistently carried out by the same method.

Ablation of Dysplastic Barrettʼs Mucosa in Scleroderma-Type Esophagus: Cold Spray over RFA: 2016 ACG Presidential Poster Award

Radiofrequency ablation (RFA) is currently the first line endoscopic therapy for eradication of dysplastic Barrett's esophagus (BE). In this modality, high frequency radio waves are applied to the esophageal mucosa by direct contact. Another option is spray cryotherapy, where liquid nitrogen is sprayed onto the mucosa, rapidly freezing the tissue as the liquid evaporates. RFA is not always successful at ablating the BE mucosa. We believe we have identified a subset of patients in whom RFA was not effective due to a dilated baggy esophagus.First described in patients with systemic sclerosis, the “scleroderma-type” esophagus is typified by a dilated, aperistaltic esophagus with an incompetent lower esophageal sphincter. Esophageal dysmotility of this kind was later described in patients with other conditions, and in those with no systemic disease at all. This population is prone to esophageal adenocarcinoma. We hypothesized that cryotherapy would be a useful adjunct in this patient population. As it does not require direct contact with the sagging esophagus, cryotherapy may succeed where RFA had failed due to difficulty in establishing tension with the baggy mucosa of scleroderma-type esophagus.We present a retrospective case series of 4 patients with endoscopic features of scleroderma-type esophagus who were treated for dysplastic BE with RFA followed by adjunctive cryotherapy. Two patients had features of systemic sclerosis (Table 1). Three patients had high-grade dysplasia (HGD), one had indefinite dysplasia (ID). The indications for adjunctive cryotherapy were persistent dysplasia and persistent metaplasia despite RFA.All patients had reduction of their BE segment length with adjunctive cryotherapy. All 3 dysplasia patients had reduction in their grade of dysplasia with cryotherapy and 2 achieved complete eradication of dysplasia (CE-D). One patient achieved complete eradication of intestinal metaplasia (CEIM). (Table 2).Table 1: Patient Demographics and Baseline CharacteristicsTable 2: Patient OutcomesIn our case series, cryotherapy was a useful complement to RFA, and achieved CE-D in most cases as well as improvement of dysplastic histology and reduction of BE length in all cases. We hypothesize that due to the non-contact nature of spray cryotherapy it may be better suited than contact RFA for treating the sagging scleroderma-type esophagus. Weaknesses of this study are its small sample size and retrospective nature. Future research may investigate cryotherapy as a first line treatment in this population.

Tu1146 Persistent and Multifocal Low Grade Dysplasia (LGD) and Topographic Location of LGD Are Not Associated With Progression to High Grade Dysplasia (HGD) or Esophageal Adenocarcinoma (EAC) in Patients With Long Segment Barrett's (Lsb)

Tu1146 Persistent and Multifocal Low Grade Dysplasia (LGD) and Topographic Location of LGD Are Not Associated With Progression to High Grade Dysplasia (HGD) or Esophageal Adenocarcinoma (EAC) in Patients With Long Segment Barrett's (Lsb)