Self-Expanding Metal Stents Confer a Survival Advantage in the Palliation of Distal Malignant Biliary Obstruction

Self-Expanding Metal Stents Confer a Survival Advantage in the Palliation of Distal Malignant Biliary Obstruction Kevin Waschke, Eduardo da Silveira, Youssef Toubouti, Elham Rahme, Alan Barkun Background: Plastic and self-expanding metal stents are used to palliate malignant biliary obstruction, yet can be complicated by occlusion. A previous set of meta-analyses by our group showed that no plastic stent design is superior and that adjuvant therapy does not improve stent patency or prolong patient survival. Objectives: To determine the effect of metal stent technologies compared with plastic stent insertion on duration of stent patency and patient survival in malignant biliary obstruction. Methods: Relevant English RCTs (1980-2004) were assessed by 2 reviewers for methodological quality using a validity assessment score created for this analysis. Data were abstracted regarding patient characteristics of stent insertion (ERCP vs. percutaneous) for distal malignant biliary obstruction, excluding hepatic metastases. Only trials with sufficient statistical information were included. The main outcomes were median stent occlusion and median patient survival. The difference of log-transformed median stent patency or survival ratio of the treatment stent vs. control was calculated for each study. Data were pooled using a random effect model and then re-transformed to the original scale to provide pooled estimates and 95% CI. Sensitivity analysis was done. SAS software (v 8.2) was used for statistical analysis. Results: A meta-analysis of 3 trials with 184 patients treated with plastic vs. self-expanding metal stent insertion showed a significant benefit for metal stents in terms of median patency (ratio 0.3, 95% CI 0.131 to 0.599 p Z 0.001). A survival advantage was also noted that favored metal stents (0.69, p Z 0.03, 95% CI 0.486 to 0.968). Conclusions: The use of metal stents results in a prolonged median patency when compared with plastic, which confirms results of individual trials. The use of SEMS was shown in this meta-analysis to provide a survival advantage when compared to plastic stents–this has never been shown in individual trials, probably due to insufficient statistical power but bears significant clinical implications. Additional high quality clinical data are required to assess this important finding. T1324 Case Finding for Celiac Disease Using Zoom Endoscopy Rawya Badreldin, Paul Barrett, John Mansfield, Yan Yiannakou Introduction: The detection of coeliac disease is often difficult as 20-50% of adult coeliac disease (CD) fails to present with malabsorptive symptoms and up to 5% have negative serology. Although coeliac disease fulfils the criteria for mass screening, the best epidemiological approach at present, is a case finding one. Using a zoom endoscope, a patients’ presentation for an endoscopy for any indication provides an opportunity to screen for villous atrophy. The role of zoom endoscopy in coeliac disease has been evaluated in only a few small studies. Aims: 1-To establish the efficacy of zoom endoscopy in detecting villous atrophy villous atrophy in a large case finding series. 2-Compare the detection of villous atrophy using conventional video and magnification endoscopy. Methods: 951 patients were prospectively recruited over a 22 month period. Patients with known coeliac disease were excluded. All endoscopies were performed by one endoscopist using the Olympus Q240Z endoscope. The duodenum was first examined for loss of folds, scalloping and a mosaic pattern. Then on full magnification of 115 normal, a score of Z1 to Z4 was allocated, with Z1 being normal villi and Z4 a flat mucosa. Results: Two patients were excluded; one with childhood coeliac disease and the other with duodenal Crohn’s disease. Of the patients referred, 147 had symptoms consistent with coeliac disease and 802 had non-suggestive symptoms. Twenty-three new cases of coeliac disease were found giving a prevalence rate of 2.42%. Seven of these patients had non-suggestive symptoms giving a prevalence rate of unsuspected CD of 0.74% in this population. Zoom endoscopy has a sensitivity of 95.65% and a specificity of 97.08% in detecting villous atrophy and a negative and positive predictive value of 99.88% and 44.89% respectively. Conclusions: Zoom endoscopy can be utilized successfully as a case finding tool for coeliac disease in patients presenting for endoscopy and is particularly useful when the diagnosis had not been considered.