early EC, 443 (19%) underwent EET [endoscopic mucosal resection (EMR) 69%, ... of endoscopic therapy as a therapeutic option for patients with early EC.
Abstracts
EET and surgery. Cox proportional hazards regression models were used to evaluate association between treatments with EC-specific mortality. Outcomes were also evaluated specifically based on histology (EAC) and stage (stage 0 vs. 1A vs. 1B). Time-trend analysis was performed by comparing proportion of pts undergoing EET vs. surgery in 3-yr intervals. Results: Of a total of 2275 pts with early EC, 443 (19%) underwent EET [endoscopic mucosal resection (EMR) 69%, EMR and ablation (16%) and ablation only 15%] and 1832 (81%) underwent surgery. Pts undergoing EET were older (p⬍0.001), less likely to be men (p⬍0.001) and more like to be diagnosed with Stage 0 and 1A disease with welldifferentiated histology (p⬍0.01). Pts undergoing surgery were more likely to have large tumors (p⬍0.001) and receive radiation (p⬍0.001). Stage 0 pts were more likely to receive EET (p⬍0.001) compared to Stage 1A and 1B. There was no statistically significant difference in the 2-year EC-free survival between the two gps (EET 76% vs. Surgery 79%, p⫽0.3) (Table 1). Excluding pts with Stage 1B disease did not impact 2-yr EC-free survival rates (EET 78% vs. Surgery 83%, p⫽0.08). Similar results were noted when outcomes were compared between EET and surgery in patients with EAC (2-yr EC-free survival: EET-78% vs. surgery-81%, p⫽0.3). EET was increasingly used in early EC pts over the period analyzed (p for trend ⬍0.01). Cox proportional hazards model showed no difference in EC-specific mortality in the EET compared to surgery group [HR: 1.2 (95% CI 0.8-1.6)]. Other variables associated with mortality were higher age, radiation therapy, stage 1A and 1B and ESCC (Table 2). Conclusions: Results of this population-based study demonstrate equivalent long-term survival in patients with early EC treated with either endoscopic therapy or surgery, with similar results noted in patients with EAC. These effectiveness data substantiate the use of endoscopic therapy as a therapeutic option for patients with early EC. Table 1. Baseline characteristics comparing patients with early EC undergoing EET and surgery Variable Mean age (yrs, SD) Men (n, %) Whites (n, %) Stage (n,%) Stage 0 Stage 1A Stage 1B Histology (n, %) EAC ESSC Others Histology grade: well differentiated Mean tumor size (mm, SD) Radiation therapy (n, %) SEER Site North-East Mid-West South West Mean follow-up within SEER (months, SD) 2-year EC free survival*
EET (nⴝ443)
Surgery (nⴝ1832)
p value
70.3 (10.4) 345 (78) 412 (93)
63.1 (10) 1556 (85) 1686 (92)
⬍0.001 ⬍0.001 0.48
142 (32) 239 (54) 62 (14)
215 (12) 771 (42) 846 (46)
⬍0.001 ⬍0.001 ⬍0.001 0.48
325 (73) 74 (17) 44 (10) 49/178 (27)
1421 (77) 237 (13) 174 (10) 201/1354 (15)
17 (16) 42 (9) 101 (23) 54 (12) 66 (15) 222 (50) 34 (36)
23 (20) 318 (17) 346 (19) 245 (13) 365 (20) 876 (48) 46 (36)
0.001 ⬍0.001 0.4
77%
79%
0.3
0.001
⬍0.001
EET, endoscopic eradication therapies; EAC, esophageal adenocarcinoma; ESCC, esophageal squamous cell cancer *% censored: EET 28%, Surgery 18%
Table 2. Predictors of EC-specific mortality in Cox proportional hazard models Variable EET vs. Surgery Age at diagnosis EAC Stage 1A Stage 1B Year of diagnosis Receipt of radiation therapy
Hazard Ratio
95% confidence interval
p value
1.2 1.02 0.69 2.81 3.85 0.96 2.69
0.87-1.66 1.01-1.03 0.56-0.84 1.79-4.42 2.45-6.05 0.92-0.99 2.19-3.32
0.24 ⬍0.001 ⬍0.001 ⬍0.001 ⬍0.001 0.04 ⬍0.001
have shown that ET offers excellent oncological outcomes, and is less invasive compared to esophagectomy. However, there is very limited population-based data comparing long term outcomes with the 2 treatment modalities. The aims of this study were to evaluate outcomes in term of esophageal cancer mortality and overall mortality for patients with early EAC treated by ET or surgery using a large national cancer database. Method: We used the SEER 18 database to identify patients with TisN0M0 and T1N0M0 histologically confirmed esophageal adenocarcinoma diagnosed between 1998 and 2009. Statistical analysis was performed using Kaplan-Meier’s estimate and compared with log-rank test. The multivariate analysis was performed with the Cox-regression method after controlling for other relevant covariates. Results: A total of 1618 patients with EAC were identified, including 1312 (81%) treated surgically and 306 (18.9%) treated with ET. ET was use more frequently in older patients, and tumors smaller than 1.5 cm with no submucosal invasion. Surgery was used more likely in male patients. The median follow-up time of the entire study population was 36 months (range 0-143). In univariate analysis, overall mortality was higher in ET group. 5-year overall survival rate of ET was 58% (SE 4.1) vs 70% (SE 1.4) in surgery group (p⫽0.003, log-rank test) but 5 year esophageal cancer free survival was similar for ET and surgery groups; 82% (SE 3.1) in ET vs 78% (SE 1.38) in surgery group (p⫽0.26, log-rank test). In a multivariate Cox proportional hazards model; adjusted for age, gender, depth of tumor invasion, year of diagnosis, site of cancer, SEER region, radiation therapy; ET and surgery resulted in statistically equivalent in overall mortality [Hazard ratio(HR) 1.23, 95% CI 0.941.62, p⫽0.12] and esophageal cancer mortality [HR 0.75, 95% CI 0.49-1.17, p⫽0.21]. Conclusion: After adjusting for comorbid conditions, overall and cancer specific survival in patients with EAC treated with ET appears to be similar to those treated with surgery. We found that patients who have significant coexisting conditions such as older age, are less likely to undergo surgery, as reflected in our study that older patients were more likely to have ET, which could partly explain higher univariate overall mortality in ET group.
Sa1467 Development and Initial Validation of Prognostic Scoring Systems for Lower Gastrointestinal Bleeding Christopher Smith, John M. Thomson, Andrew Fraser, Balasubramaniam Vijayan, Emad El-Omar, John S. Leeds* Department of Gastroenterology, Aberdeen Royal Infirmary, Aberdeen, United Kingdom Background: Lower gastrointestinal bleeding (LGIB) is a common and heterogeneous condition, in which there is a paucity of data concerning predictors of adverse outcomes. This study aimed to identify independent risk factors for adverse outcomes in LGIB, and derive prognostic scoring systems to stratify patients by risk on admission. Methods: The Aberdeen bleeding unit opened in 1991 and has recorded demographics, presenting symptoms, haemodynamic status and outcomes on all admissions in a comprehensive database. Analysis was performed on admissions due to LGIB over the period 1991 to 2005. Independent risk factors for re-bleeding, requirement for surgical intervention, and mortality at 30 days were elucidated by means of univariate and multivariate binary logistic regression analyses. Risk factors were then modelled into simple numerical prognostic scoring systems which underwent preliminary validation tests in order to determine their predictive performance using receiver operating curve analysis. Results: Over the study period, 2385 patients were admitted with LGIB. With respect to patient outcomes, 322 (13.5%) experienced re-bleeding, 135 (5.7%) required surgery and 129 (5.6%) died within 30 days. Multivariate analysis revealed that re-bleeding was associated with inpatient status (OR 1.8; 95% CIs 1.3-2.5), age 60-79 (OR 1.5; 95% CIs 1.0-2.3), age ⬎80 (OR 2.1; 95% CIs 1.3-3.2), syncope (OR 2.3; 95% CIs 1.5-3.6), underlying malignancy (OR 2.1; 95% CIs 1.0-4.3), hypotension (OR 2.3; 95% CIs 1.43.6) and haemoglobin ⬍10g/dL (OR 5.0; 95% CIs 2.8-8.9). 30 day mortality was associated with inpatient status (OR 3.3; 95% CIs 2.0-5.4), age 60-79 (OR 3.3; 95% CIs 1.5-7.1), age ⬎80 (OR 6.0; 95% CIs 2.6-13.7), underlying liver disease (OR 7.2; 95% CIs 2.9-17.7), hypotension (OR 2.9; 95% CIs 1.5-5.3), and tachycardia (OR 2.1; 95% CIs 1.3-3.6). A prognostic scoring system (0-7) was created for each mortality and re-bleeding outcomes, with area under ROC curves 0.802 and 0.742 respectively. A score of 0 reflected a re-bleeding risk of 1.1% and 30 day mortality of 0.0%, whereas a score of 6 reflected a re-bleeding risk and 30 day mortality risk of 50% in both scoring systems. Conclusions: These scoring systems can be used to calculate re-bleeding risk and 30 day mortality in patients with LGIB. Further external validation and confirmation is required.
Sa1466 Survival of Patients With Early Stage Esophageal Adenocarcinoma Treated With Endoscopic Treatment or Surgical Resection: an Analysis of Surveillance, Epidemiology, and End Results (SEER) Database Saowanee Ngamruengphong*, Herbert C. Wolfsen, Michael B. Wallace Mayo Clinic Florida, Jacksonville, FL
Sa1468 Impact of Gastrointestinal Hemorrhage in Acute Myocardial Infarction: Analysis of the Nationwide Inpatient Sample Joseph L. Yeh*, Bechien U. Wu Gastroenterology, Kaiser Permanente Los Angeles Medical Canter, Los Angeles, CA
Background: Endoscopic therapy (ET) is an emerging therapeutic option for patients with early esophageal adenocarcinoma (EAC). Several previous studies
Introduction: Advancements in antithrombotic regimens and revascularization techniques, including percutaneous coronary intervention (PCI), have been
AB216 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
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