Serge Mayrand

The Stretta procedure versus proton pump inhibitors and laparoscopic Nissen fundoplication in the management of gastroesophageal reflux disease: A cost-effectiveness analysis

BACKGROUND The Stretta procedure is an endoscopic therapy for gastroesophageal reflux disease. OBJECTIVE To evaluate the cost-effectiveness of the Stretta procedure and that of competing strategies in the long-term management of gastroesophageal reflux disease. METHODS A Markov model was designed to estimate costs and health outcomes in Canadian patients with gastroesophageal reflux disease over five years, from a Ministry of Health perspective. Strategies included the use of daily proton pump inhibitors (PPIs), laparoscopic Nissen fundoplication (LNF) and the Stretta procedure. Probabilities and utilities were derived from the literature. Costs are expressed in 2006 Canadian dollars. Units of effectiveness were symptom-free months (SFMs) and quality-adjusted life years (QALYs), using a five-year time horizon. RESULTS In the analysis that used SFMs, the strategy using PPIs exhibited the lowest costs (

Randomized controlled trial comparing outcomes of video capsule endoscopy with push enteroscopy in obscure gastrointestinal bleeding

40 per SFM) and the greatest number of SFMs, thus dominating both the LNF and Stretta systems. But the cost-effectiveness analysis using QALYs as the measure of effectiveness showed that PPIs presented the lowest cost-effectiveness ratio, while both the LNF and Stretta strategies were associated with very high incremental costs (approximately

A New Approach to Analysis and Modeling of Esophageal Manometry Data in Humans

353,000 and

The Potential Impact of Contemporary Developments in the Management of Patients with Gastroesophageal Reflux Disease Undergoing an Initial Gastroscopy

393,000, respectively) to achieve an additional QALY. However, the PPI strategy did not dominate the two other strategies, which were associated with better effectiveness. CONCLUSIONS If SFMs are used as the measure of effectiveness, PPIs dominate the Stretta and LNF strategies. However, if QALYs are used, the PPIs still present the lowest cost and LNF gives the best effectiveness. Regardless of the units of effectiveness or utility used in the present cost analysis, an approach of prescribing PPIs appears to be the preferred strategy.

Tu1074 Videocapsule Versus Enteroscopy in Patients With Obscure GI Bleeding: Results of a Randomized Controlled Trial

BACKGROUND Optimal management of obscure gastrointestinal bleeding (OGIB) remains unclear. OBJECTIVE To evaluate diagnostic yields and downstream clinical outcomes comparing video capsule endoscopy (VCE) with push enteroscopy (PE). METHODS Patients with OGIB and negative esophagogastroduodenoscopies and colonoscopies were randomly assigned to VCE or PE and followed for 12 months. End points included diagnostic yield, acute or chronic bleeding, health resource utilization and crossovers. RESULTS Data from 79 patients were analyzed (VCE n=40; PE n=39; 82.3% overt OGIB). VCE had greater diagnostic yield (72.5% versus 48.7%; P<0.05), especially in the distal small bowel (58% versus 13%; P<0.01). More VCE-identified lesions were rated possible or certain causes of bleeding (79.3% versus 35.0%; P<0.05). During follow-up, there were no differences in the rates of ongoing bleeding (acute [40.0% versus 38.5%; P not significant], chronic [32.5% versus 45.6%; P not significant]), nor in health resource utilization. Fewer VCE-first patients crossed over due to ongoing bleeding (22.5% versus 48.7%; P<0.05). CONCLUSIONS A VCE-first approach had a significant diagnostic advantage over PE-first in patients with OGIB, especially with regard to detecting small bowel lesions, affecting clinical certainty and subsequent further small bowel investigations, with no subsequent differences in bleeding or resource utilization outcomes in follow-up. These findings question the clinical relevance of many of the discovered endoscopic lesions or the ability to treat most of these effectively over time. Improved prognostication of both patient characteristics and endoscopic lesion appearance with regard to bleeding behaviour, coupled with the impact of therapeutic deep enteroscopy, is now required using adapted, high-quality study methodologies.

Predicting which patients can undergo upper endoscopy comfortably without conscious sedation

In this paper, we propose a new approach to the analysis and modeling of esophageal manometry (EGM) data to assist the diagnosis of esophageal motility disorders in humans. The proposed approach combines three techniques, namely, wavelet decomposition (WD), nonlinear pulse detection technique (NPDT), and statistical pulse modeling. Specifically, WD is applied to the filtering of the EGM data, which is contaminated with electrocardiography (ECG) artifacts. A new NPDT is applied to the denoised data leading to identification and extraction of diagnostically important information, i.e., esophageal pulses from the respiration artifacts. Such information is used to generate a statistical model that can classify the EGM patterns. The proposed approach is computationally effortless, thus making it suitable for real-time application. Experimental results using measured EGM data of 20 patients, including ten abnormal cases is presented. Comparison of our results with those from existing techniques illustrates the advantages of the proposed approach in terms of accuracy and efficiency.

Gastroesophageal reflux and hyperacidity in chronic renal failure

BACKGROUND Recent developments may alter the approach to patients presenting with gastroesophageal reflux disease (GERD)-like symptoms. A newly proposed Montreal consensus definition of Barretts esophagus includes all types of esophageal columnar metaplasia, with or without intestinal-type metaplasia. There is also increasing recognition of eosinophilic esophagitis (EE) in patients with GERD-like symptoms. OBJECTIVE To quantify the impact of these developments on a multiphysician general gastroenterology practice in a tertiary care medical centre. METHODS Medical charts of all patients having an initial gastroscopy for GERD-like symptoms over a one-year period were reviewed retrospectively, and audits of their endoscopic images and esophageal biopsies were performed. RESULTS Of the 353 study participants, typical symptoms of heartburn and acid reflux were present in 87.7% and 23.2%, respectively. Less commonly, patients presented with atypical symptoms (eg, dysphagia in 9.4%). At endoscopy, 26% were found to have erosive esophagitis and 12% had endoscopically suspected esophageal metaplasia. Histological evaluation was available for 65 patients. Ten of the 65 biopsied patients (15%) met traditional criteria for Barretts esophagus (ie, exhibiting intestinal-type metaplasia), whereas 49 (75%) fulfilled the newly proposed consensus definition of Barretts esophagus. Five patients (7.7%) met the study criteria for EE (more than 20 eosinophils per high-power field), four of whom had not been previously recognized. CONCLUSIONS Among patients presenting with GERD-like symptoms, the prevalence of Barretts esophagus may increase markedly if the Montreal definition is adopted. In addition, growing awareness of EE may lead to an increase in the prevalence of this diagnosis. Prospective studies of the management implications of these findings are warranted.

Is Helicobacter pylori eradication associated with the endoscopic development of esophagitis

Background: Videocapsule endoscopy (VCE), when compared to enteroscopy (E), is associated with increased detection of mucosal lesions in obscure gastrointestinal bleeding (OGB). However, few randomized trials have compared these two modalities, and data on clinical relevance are lacking. The aim of this study was to compare VCE with E in terms of diagnostic yield and subsequent clinical outcome. Methods: We randomly allocated adult patients with occult bleeding (iron deficiency anemia >6 months needing blood transfusion or iron supplementation with repeated positive stool occult blood testing) or overt bleeding (≥1episode of melena/hematochezia within 7 days of presentation and a hemoglobin drop ≥15 g/dL) to VCE or E after a negative initial work-up (single or repeated gastroscopy and colonoscopy examinations with or without small bowel radiology). The main outcomes were recurrence and persistence of bleeding using standardized criteria defined a priori over 1year. Crossovers were permitted after the main outcome was reached. Results: 79 patients (68.5±14.5yrs, 36.7% female) were included over a 5-year period. 40 subjects were allocated to VCE and 39 to E (of push type). Overall, 76.0% presented with overt bleeding. At baseline, 24.1% were taking ASA, 11.4% an anticoagulant, and 2.5% an NSAID; 76.7% of patients had a nuclear scan, and 37.0% an angiography. No significant differences were noted in baseline characteristics between the two groups. At least one lesion was detected in 72.5% of the VCE group compared to 48.7% in the E group (p=0.03); they were believed to be the source of bleeding in 79.3% and 35.0% (p=0.002), respectively. Although detection rates were similar for gastric and duodenal findings, VCE performed better in the first and second parts of the jejunum (50% vs. 10.3% P=0.0001, and 40% vs. 2.6% P<0.0001). No disparities were observed in terms of the nature of the lesions found between the two modalities. Mean duration of follow-up was 289.0±118.8 days, with 50.0% requiring a blood transfusion (42.5% VCE vs. 57.9% E, with a mean of 2.9 ± 5.0 units (VCE: 2.8±4.3 units vs. E: 3.0±5.6 units, P=NS)). Hospitalization for bleeding or continued bleeding occurred in 40.0% of VCE and in 53.9% of E patients (P=NS) (mean stay: 11.0±11.9 and 18.5±28.2 days respectively, P=NS). Crossovers occurred more frequently from E to VCE than from VCE to E (48.7% vs. 22.5%, P=0.015). Conclusions: VCE increases diagnostic yield in OGB when compared to E, especially when the bleeding source is in the jejunum. However, subsequent impact on clinical care was not significantly better in this trial although trends favored the VCE group. More crossovers were noted from E to VCE than conversely. Overall, our data support the use of VCE over E following an initial work-up in patients with OGB.