Abstracts

525

What Are the Outcomes of Endoscopic Radiofrequency Ablation

for Very Long Segments of Barrett Esophagus Containing

Neoplasia?Lorenza Alvarez Herrero, Roos E. Pouw, Frederike G. Van Vilsteren,Carine Sondermeijer, Fiebo J. Ten Kate, Paul Fockens, Bas L. Weusten,Jacques BergmanBackground: Radiofrequency ablation (RFA) is safe and effective for eradicatingBarrett esophagus (BE) and neoplasia. Most studies have limited the baselinelength of BE (!10 cm) and little is therefore known about RFA for very long BEsegments. Aim: Assess the safety and efficacy of RFA for BE R10 cm containingneoplasia. Methods: Eligible patients (pts) had BE R10 cm with LGD, HGD or earlycancer (EC). Pts underwent focal endoscopic resection (ER) for visible lesions,followed by circumferential (C-RFA) and focal RFA (F-RFA) every 2-3 mo untilcomplete remission achieved (CR, defined as endoscopic resolution of BE and noevidence of intestinal metaplasia (IM) or neoplasia on biopsy). Follow-up (FU)endoscopy with 4Q/2 cm biopsies was performed at 2, 6, and 12 mo. Results: 26consecutive pts were included (21 M, age 66 yrs, median BE length 11cm, range 10-20). Baseline ER was performed in 18/26 pts: EC (11), HGD (6), LGD (1). Worstgrade of residual BE prior to RFA (and after ER as applicable): HGD (16), LGD(10).At entry, 13 pts (50%) had a proximal reflux stenosis (3 required dilation). Aftercircumferential RFA, 7/26 (27%) had a non-transmural laceration (4 at the refluxstenosis, 3 at the prior ER). All were able to complete RFA. One pt with a relativestenosis after ER, developed dysfagia after RFA and required dilatation.By Nov’08, 9pts are still under treatment (median regression: 95%), in 3 pts (12%) treatmentwas discontinued due to poor neosquamous regeneration. 14 pts have completedtreatment with CR-IM and CR-neoplasia achieved after a median of 1(IQR 1-1) C-RFA and 2(IQR 1-3) F-RFA sessions. Two pts had a focal ER for small persistingislands after RFA. After a median FU of 9 mo, no recurrence of neoplasia was found.In 1 pt a 0.5mm island was found during FU, distal to a reflux stenosis at the upperend of the initial BE. One pt had focal IM detected at the neo-z-line at a single FUendoscopy. No buried BE was found in 752 neosquamous biopsies. Conclusion: Ptshaving very long segments of BE (10-20 cm in this evaluation) present challengesthat we have not observed in our more typical BE pts: 12% of our pts with BER10cm showed poor healing after RFA, probably reflecting the severity of theunderlying reflux disease. Reflux stenoses and scarring after ER resulted insuperficial laceration after circumferential RFA in 27% of pts, but these events weremanageable. Overall we were able to achieve a CR in 14/17 who have completedtherapy in a similar number of RFA sessions as required in shorter segment BEcohorts. Aside from the challenges noted, very long segments of BE can be treatedsafely and effectively with RFA.

610

Diagnostic Accuracy of a New Shortened Peroral

Cholangioscope in Indeterminate Biliary Stricures and Filling

DefectsChristian Prinz, Steffi Goeke, Andreas Weber, Alexander Meining, RolandM. Schmid, Eckart FrimbergerBackground: Suspicious biliary strictures and filling defects are a diagnosticchallenge in endoscopic practice. A new 95 cm shortened peroral cholangioscopy(sPOCS) introduced through the lateral port of the duodenoscope was developedto improve diagnostic approaches in patients with indeterminate biliary stricturesor filling defects. Patients and Methods: In the study period from January 2007 toNovember 2008, 58 consecutive patients (25 men, 33 women; mean age 63 years)were included in this prospective trial. Endoluminal appearance and biopsies wereobtained in 40 patients with indeterminate strictures, 18 patients had filling defects.The diagnostic accuracy of sPOCS in visualisation of strictures and tissue samplingwas evaluated, therapeutic success was monitored. Results: 40 patients hadindeterminate strictures. Using the criteria ‘‘circular stenosis’’ and ‘‘irregular surfaceor margins’’, sPOCS correctly described all 16 out of 17 malignant biliary strictures,and correctly described 21 out of 23 benign lesions (sensitivity, 94.1%; specificity,91.3%). Visually targeted forceps biopsies were performed in 42 patients, i.e. 40strictures and 2 patients with filling defects. Tissue sampling during sPOCS revealedmalignant tissue in 11 of 17 cases (Sensitivity: 64.7%, respectively). In 18 patientswith filling defects, 7 patients with bile duct stones were successfully withconventional stone removal. 9 patients with difficult stones (4 giant stones and 5intrahepatic stones) were treated with visually guided laserlithotrypsy and stoneremoval. 2 patients had biliary polyps and were surgically resected or received livertransplantation. Conclusion: The new shortened 95 cm sPOCS allows accuratedetection of malignant tumors in the biliary tree, and shows improved sensitivity ofendoscopically guided forceps biopsies in up to 65%. Filling defects are accuratelydistinguished. Intrahepatic stones could be reached and successfully treated in allpatients investigated.

AB116 GASTROINTESTINAL ENDOSCOPY Volume 69, No. 5 : 2009

611

It Looks Like Cholangiocarcinoma - But Is It? Cholangioscopy

Using a Cholangioscopy System for Diagnosis of

Cholangiocarcinoma in Patients with Primary Sclerosing

CholangitisAlexander Dechene, Philip A. Hilgard, Amr El Fouly, Guido Gerken,Thomas ZoepfIntroduction: Patients with primary sclerosing cholangitis (PSC) are at increasedrisk of developing cholangiocarcinoma (CC). The absence of early symptoms of CCand the lack of reliable diagnostic instruments for early detection of the tumorcontribute to the dismal prognosis of CC in PSC patients. Direct visualization of thebiliary system with cholangioscopy is not (yet) a standard tool for excludingmalignancy in bile duct stenoses, but certain cholangioscopic characteristics of CChave been described, such as polypoid or villous intraductal masses, taperednarrowing, ductal ulceration and torqued tumor vessels. The SpyGlasscholangioscopy system (SG), which offers a novel technique for depiction of thebiliary tract, may be an option for differentiation of suspicious ductal lesions. Aim:To evaluate the characteristics of bile duct lesions in patients with PSC using the SGand compare the characteristics of cholangiocarcinoma given in the literature withthe cholangioscopic findings in combination with histologic, cytologic an follow-upresults. Methods: Between 01/08 - 07/08, 17 patients with cholangiographicallyproven PSC (11 men, 6 women, median age 41years) underwent SGcholangioscopy following ERCP. In all patients, stenoses of the common or the mainhepatic bile ducts were present. Cholangioscopy using SG was performed in all 17patients. Results15/17 (88%) of all patients showed signs of active inflammation,such as epithelial redness, fibrin exudation and contact vulnerability at the site ofstenosis. Predefined stigmata of malignancy were present in 11 patients: polypoidmasses in 4/17 (23%), villous protrusions of the ductal wall in 5/17 (29%) patients. Atapered, smooth narrowing of main ducts was seen in 2/17 (11%) patients. Ductalulceration and torqued tumor vessels were not seen in any patient. Forcepsbiopsies and/or brush cytology from the lesion was taken in all 11 patients withsuspected signs of CC. All samples were classified as non-malignant by experiencedpathologists. During a follow-up period of mean 7 months, none of the 17 patientsdeveloped symptoms of CC (unexpected weight loss, jaundice, excessive raise in CA19-9 or positive imaging studies). Conclusion: Using SG, visualization of ductalstenoses in PSC can be accomplished well. Determining the dignity of lesions usingthe cholangioscopic characterization of CC given in the literature does not seem tobe possible if ulceration and tumor vessels are absent. Polypoid or villousintraductal masses and a tapered narrowing of ducts do not necessarily representCC in PSC patients. Further evaluations with larger cohorts and extended follow-upperiods are needed.

612

3D Imaging of Intrahepatic Strictures During Endoscopic

Retrograde Cholangiography (ERC): First Clinical DataKatja Wirths, Said Gannoun, Thomas ZoepfIn contrast to other imaging techniques ERC combines diagnostic and therapeuticoptions. In case of Klatskin tumors, strictures can be visualized, diagnosed bybiopsy specimen or brush cytology and treated e.g. by stent placement at the sameprocedure. With regard to surgical resection techniques an exact estimation of theextention of the tumor into the hepatic ducts is mandatory but still difficult. Ina pilot trial patients with intrahepatic bile duct strictures underwent diagnostic ERCwith three-dimensional (3D) angiographic reconstruction of the bile duct system involume rendering technique. The aim of this trial was to compare both imagingmodalities with regard to the potential of imaging the stricture morphology.Patients/Methods: Consecutive patients with known bile duct strictures underwentERC in prone position with intravenously administered midazolam and propofolwith constant monitoring of oxygen saturation and heart rate as well as bloodpressure in intervals. In a first step the contrast filled bile ducts are viewed fromdifferent positions using the rotational capabilities of the C-arm. In a second stepa 3D volume rendering technique is undertaken: 99 projection images are recordedduring the 5 second rotation of the C-arm and this dataset is automaticallyreconstructed and displayed on a different screen. A special software providesvirtual 3D rotation of the bile duct system, enabling the examiner to look at thestrictures from different positions. Results: Five consecutive patients werepresented for intrahepatic strictures (Klatskin type IV nZ2, intrahepatic stenosis ofthe left hepatic duct nZ2 and of the right hepatic duct nZ1). ERC with threedimensional reconstruction was successful in all examinations. All of the knownstrictures were visualized in 3D imaging. Analysis of length and number as well asdegree of strictures was facilitated by 3D imaging. Due to the evaluation of the bileduct system from different virtual positions with 3D reconstruction analysis oflength, number and degree of strictures was facilitated. In one patient 3D analysisshowed an only slight stricture without need for treatment that had been estimateddifferently in conventional two-dimensional ERC imaging. Conclusion: Online threedimensional imaging of intrahepatic strictures during ERC is feasible. 3D ERC hasthe advantage of imaging intrahepatic strictures from different virtual positions thusmay improve analysis of duct morphology and tumor staging and may haveimplications on therapeutic interventions. This hypothesis has to be confirmed inlarger trials.

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