An audit of the use of psychotropic medications over the course of admission to a specialist dementia ward

AimsThe aim of this audit project was to establish the practices in prescribing and de-prescribing of psychotropic medications for patients on a specialist dementia ward.BackgroundThere is a great deal of evidence demonstration high rates of polypharmacy, defined as ≥5 drugs, in older adults in general and in those with dementia more specifically. NICE guidelines recommend a structured assessment of a patient with dementia to exclude other potential causes, e.g. pain or delirium. Psychosocial interventions are recommended as first line. Antipsychotics should only be offered second line who present a risk to themselves or others. These should only be used for the shortest time possible and reassessed at least every 6 weeks.MethodData were collected for patients (n = 20) discharged from a specialist dementia ward between September 2018 and March 2019. The unit has 14 beds caring for patients with predominantly severe behavioural and psychological symptoms associated with dementia (BPSD). The team is comprised of doctors, nurses, a clinical psychologist, occupational therapists, physiotherapists and pharmacists who meet twice a week to review patients. Data were coded by drug class and counts of medication on admission, at the midpoint and at discharge were conducted. Antipsychotic and benzodiazepine dosages were converted into haloperidol and diazepam equivalence.ResultOf the 20 patients, 70% were male and 30% female. 95% of the patient (n = 19) were admitted under the Mental Health Act (1983). 20% were managed on 1 to 1 observations and 80% were on 15 min observations. In general, the results show little change in the overall rate of psychotropic prescribing. The mean number of psychotropic medications prescribed per patient on admission was 2.30, at the mid-point of admission it was 2.30 and at discharge it was 2.05. Mean benzodiazepine dosage in diazepam equivalence reduced between admission and discharge from 3.20 mg to 2.10 mg. Mean haloperidol equivalent dosages increased at the midpoint of admission from 1.11 mg to 2.27 mg before reducing to 0.78 mg at discharge.ConclusionThe results demonstrate minimal change in the overall average number and composition of drugs prescribed. There are differences in the use of regular antipsychotics and benzodiazepines between admission and discharge which are consistent with NICE guidelines. Patients had a structured assessment with regular medicines reconciliation supervised by the team pharmacist. Therefore, the ward environment did allow for detailed discussions about de-prescribing which may not be the case elsewhere.

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Pharmacologic management of behavioral and psychological symptoms of major neurocognitive disorder

Mental Health Clinician ◽

10.9740/mhc.2018.11.284 ◽

2018 ◽

Vol 8 (6) ◽

pp. 284-293 ◽

Cited By ~ 2

Author(s):

Monica Mathys

Keyword(s):

Psychological Symptoms ◽

Psychotropic Medications ◽

Evidence Based ◽

Neurocognitive Disorder ◽

Medication Regimen ◽

First Line ◽

Risks And Benefits ◽

Pharmacologic Management ◽

Behavioral And Psychological Symptoms ◽

First Line Treatment

Abstract Behavioral and psychological symptoms of dementia (BPSD) occur in approximately 80% of patients who receive a diagnosis of major neurocognitive disorder. Nonpharmacologic strategies are the first-line treatment for BPSD. However, psychotropic medications are often necessary when nonpharmacologic methods are not effective in treating symptoms that are distressing or are causing behaviors that are dangerous to the patient or the patient's caregivers. The article provides a review of evidence-based recommendations for the use of antipsychotics, cognitive enhancers, and serotonin reuptake inhibitors for the treatment of BPSD. Different pharmacologic approaches are demonstrated through 2 patient cases in which nonpharmacologic management was not effective. The severity of BPSD must be weighed against the risks and benefits of pharmacologic intervention in order to implement an optimal medication regimen.

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A cross-sectional examination of the prevalence of psychotropic medications for people living with dementia in Australian long-term care facilities: issues of concern

International Psychogeriatrics ◽

10.1017/s1041610217002447 ◽

2017 ◽

Vol 30 (7) ◽

pp. 1019-1026 ◽

Cited By ~ 9

Author(s):

Mitchell McMaster ◽

Elaine Fielding ◽

David Lim ◽

Wendy Moyle ◽

Elizabeth Beattie ◽

...

Keyword(s):

Behavioral Interventions ◽

Long Term Care ◽

Psychological Symptoms ◽

Psychotropic Medications ◽

Background Information ◽

First Line ◽

Cross Sectional ◽

Term Care ◽

Care Facilities

ABSTRACTBackground:Behavioral and psychological symptoms of dementia (BPSD) are a common problem in long-term care facilities (LTC). Clinical guidelines dictate that first-line treatments for BPSD are psychosocial and behavioral interventions; if these are unsuccessful, psychotropic medications may be trialed at low doses and their effects can be monitored.Methods:There have previously been no studies with nationally representative samples to investigate psychotropic administration in LTCs in Australia. This study determines the prevalence of psychotropic administration in a representative stratified random sample of 446 residents living with dementia from 53 Australian LTCs. Questionnaire and medical chart data in this study is drawn from a larger cross-sectional, mixed methods study on quality of life in Australian LTCs.Results:It was found that 257 (58%) residents were prescribed psychotropic medications including: antipsychotics (n = 160, 36%), benzodiazepines (n = 136, 31%), antidepressants (n = 117, 26%), and anti-dementia medications (n = 9, 2%). BPSD were found to be very common in the sample, with 82% (n = 364) of participants experiencing at least one BPSD. The most prevalent BPSD were depression (n = 286, 70%) and agitation (n = 299, 67%).Conclusions:Although detailed background information was not collected on individual cases, the prevalence found is indicative of systematic industry-wide, over-prescription of psychotropic medications as a first-line treatment for BPSD. This study highlights a clear need for further research and interventions in this area.

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422 - Evaluating the Clinical Impact of National Dementia Behavior Support Programs on Neuropsychiatric Outcomes in Australia

International Psychogeriatrics ◽

10.1017/s1041610221001812 ◽

2021 ◽

Vol 33 (S1) ◽

pp. 44-44

Author(s):

Atee M ◽

Macfarlane S ◽

Morris T ◽

Whiting D ◽

Healy M ◽

...

Keyword(s):

Behavior Management ◽

Psychological Symptoms ◽

Neuropsychiatric Symptoms ◽

Psychosocial Interventions ◽

Aged Care ◽

Support Programs ◽

Residential Aged Care ◽

Behavior Support ◽

Average Case ◽

The Mean

Background:People living with dementia (PLWD) in residential aged care homes (RACHs) are frequently prescribed psychotropic medications due to the high prevalence of neuropsychiatric symptoms, also known as behaviors and psychological symptoms of dementia (BPSD). However, the gold standard to support BPSD is using psychosocial/non-pharmacological therapies.Objective:This study aims to describe and evaluate services and neuropsychiatric outcomes associated with the provision of psychosocial person-centered care interventions delivered by national multidisciplinary dementia-specific behavior support programs.Methods:A 2-year retrospective pre-post study with a single-arm analysis was conducted on BPSD referrals received from Australian RACHs to the two Dementia Support Australia (DSA) programs, the Dementia Behavior Management Advisory Service (DBMAS) and the Severe Behavior Response Teams (SBRT). Neuropsychiatric outcomes were measured using the Neuropsychiatric Inventory (NPI) total scores and total distress scores. The questionnaire version “NPI-Q” was administered for DBMAS referrals whereas the nursing home version “NPI-NH” was administered for SBRT referrals. Linear mixed effects models were used for analysis, with time, baseline score, age, sex, and case length as predictors. Clinical significance was measured using Cohen’s effect size (d; ≥0.3), the mean change score (MCS; 3 points for the NPI-Q and 4 points for the NPI-NH) and the mean percent change (MPC; ≥30%) in NPI parameters.Results:A total of 5,914 referrals (55.9% female, age 82.3 ± 8.6 y) from 1,996 RACHs were eligible for analysis. The most common types of dementia were Alzheimer’s disease (37.4%) and vascular dementia (11.7%). The average case length in DSA programs was 57.2 ± 26.3 days. The NPI scores were significantly reduced as a result of DSA programs, independent of covariates. There were significant reductions in total NPI scores as a result of the DBMAS (61.4%) and SBRT (74.3%) programs. For NPI distress scores, there were 66.5% and 69.1% reductions from baseline for the DBMAS and SBRT programs, respectively. All metrics (d, MCS, MPC) were above the threshold set for determining a clinically significant effect.Conclusions:Multimodal psychosocial interventions delivered by DSA programs are clinically effective as demonstrated by positive referral outcomes, such as improved BPSD and related caregiver distress.Word count:350 words

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Evaluating the Clinical Impact of National Dementia Behaviour Support Programs on Neuropsychiatric Outcomes in Australia

Frontiers in Psychiatry ◽

10.3389/fpsyt.2021.652254 ◽

2021 ◽

Vol 12 ◽

Author(s):

Stephen Macfarlane ◽

Mustafa Atee ◽

Thomas Morris ◽

Daniel Whiting ◽

Madeleine Healy ◽

...

Keyword(s):

Psychological Symptoms ◽

Neuropsychiatric Symptoms ◽

Psychosocial Interventions ◽

Change Score ◽

Aged Care ◽

Support Programs ◽

Residential Aged Care ◽

Average Case ◽

Questionnaire Version ◽

The Mean

Background/Objective: People living with dementia (PLWD) in residential aged care homes (RACHs) are frequently prescribed psychotropic medications due to the high prevalence of neuropsychiatric symptoms, also known as behaviours and psychological symptoms of dementia (BPSD). However, the gold standard to support BPSD is using psychosocial/non-pharmacological therapies. This study aims to describe and evaluate services and neuropsychiatric outcomes associated with the provision of psychosocial person-centred care interventions delivered by national multidisciplinary dementia-specific behaviour support programs.Methods: A 2-year retrospective pre-post study with a single-arm analysis was conducted on BPSD referrals received from Australian RACHs to the two Dementia Support Australia (DSA) programs, the Dementia Behaviour Management Advisory Service (DBMAS) and the Severe Behaviour Response Teams (SBRT). Neuropsychiatric outcomes were measured using the Neuropsychiatric Inventory (NPI) total scores and total distress scores. The questionnaire version “NPI-Q” was administered for DBMAS referrals whereas the nursing home version “NPI-NH” was administered for SBRT referrals. Linear mixed effects models were used for analysis, with time, baseline score, age, sex, and case length as predictors. Clinical significance was measured using Cohen's effect size (d; ≥0.3), the mean change score (MCS; 3 points for the NPI-Q and 4 points for the NPI-NH) and the mean percent change (MPC; ≥30%) in NPI parameters.Results: A total of 5,914 referrals (55.9% female, age 82.3 ± 8.6 y) from 1,996 RACHs were eligible for analysis. The most common types of dementia were Alzheimer's disease (37.4%) and vascular dementia (11.7%). The average case length in DSA programs was 57.2 ± 26.3 days. The NPI scores were significantly reduced as a result of DSA programs, independent of covariates. There were significant reductions in total NPI scores as a result of the DBMAS (61.4%) and SBRT (74.3%) programs. For NPI distress scores, there were 66.5% and 69.1% reductions from baseline for the DBMAS and SBRT programs, respectively. All metrics (d, MCS, MPC) were above the threshold set for determining a clinically significant effect.Conclusions: Multimodal psychosocial interventions delivered by DSA programs are clinically effective as demonstrated by positive referral outcomes, such as improved BPSD and related caregiver distress.

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Behavioural and psychological symptoms of dementia: a new framework for holistic understanding and non-pharmacological management

BJPsych Advances ◽

10.1192/bja.2021.12 ◽

2021 ◽

pp. 1-10

Author(s):

Ian Andrew James ◽

Kristina Gray ◽

Esme Moniz-Cook ◽

Katy Lee ◽

Katharina Reichelt ◽

...

Keyword(s):

Psychological Symptoms ◽

Equal Weight ◽

First Line ◽

Pharmacological Management ◽

Nice Guidelines ◽

Professional Groups ◽

Holistic Understanding ◽

Behavioural And Psychological Symptoms ◽

New Framework ◽

Main Strategy

SUMMARY The National Institute for Health and Care Excellence (NICE) informs us that the first-line treatments for behavioural and psychological symptoms of dementia (BPSD) are non-pharmacological. Although psychotropics used to be the main strategy in the management of behaviours that challenge, there has been an increase in the use of biopsychosocial formulations since 2010, and there are now over a dozen to choose from. However, many are overly focused on obtaining information about the agitation, and less specific about providing details of the actions required to manage the behaviours. The NICE guidelines too fail to provide specific guidance on which non-pharmacological approaches to use. This article argues for giving equal weight to both the collection of meaningful information and the development of ‘informed actions’, because it is the actions that lead to change. The article outlines a management programme providing a framework for the assessment, formulation and treatment of agitation in dementia. The work draws on theory, evidence-based practice and practice-based evidence to provide a model with sufficient structure and flexibility to be useful for clinicians across a range of settings and professional groups.

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Developing a virtual reality for people with dementia in nursing homes based on their psychological needs: a feasibility study

BMC Geriatrics ◽

10.1186/s12877-021-02125-w ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Jung-Hee Kim ◽

Seonmin Park ◽

Hyeongji Lim

Keyword(s):

Virtual Reality ◽

Nursing Homes ◽

Intervention Program ◽

Psychological Symptoms ◽

Likert Scale ◽

Psychological Needs ◽

Second Phase ◽

People With Dementia ◽

The Mean ◽

Behavioral And Psychological Symptoms

Abstract Background The purpose of this study was (1) to develop a virtual reality (VR) intervention program based on the psychological needs of patients residing in nursing facilities in South Korea to alleviate their behavioral and psychological symptoms and (2) to confirm the possibility of utilizing VR in patients with dementia. Methods In the first phase, patients with dementia residing in nursing homes and experiencing behavioral and psychological symptoms were recruited. Surveys and questionnaires were used to identify activities that alleviated the behavioral and psychological symptoms of dementia (BPSD) among the patients. These activities were classified into five types of psychological needs. In the second phase, a fully immersive, interactive, easy-to-use VR platform was developed that reflected these psychological needs. Patients with dementia experienced the VR content. The researchers assessed the level of the participants’ immersion, preference, and interaction with the VR using a 5-point Likert scale. Results In the feasibility test, 10 nursing home residents were recruited. The mean immersion score was 4.93 ± 0.16 points, the mean preference score was 4.35 ± 0.41 points, and the mean interaction score was 3.84 ± 0.43 points using a 5-point Likert scale. Higher mean scores indicated a more positive outcome. Six of the 10 participants required assistance while using the VR. The mean VR experience duration was 10.00 ± 3.46 min. Conclusions The VR-based intervention program that was developed to reduce BPSD was feasible for the participants and provided them with a high degree of satisfaction and immersion. Furthermore, this study also confirmed the convenience and safety of the program. These findings support the potential use of VR-based BPSD intervention programs to treat patients with dementia.

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Real world cost and health outcomes of patients presented with chest pain in England: which is the most cost-effective first-line test?

European Heart Journal ◽

10.1093/ehjci/ehaa946.3547 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

A Tsiachristas ◽

H West ◽

E.K Oikonomou ◽

B Mihaylova ◽

N Sabharwall ◽

...

Keyword(s):

Chest Pain ◽

Health Outcomes ◽

Diagnostic Tests ◽

Clinical Presentation ◽

Cost Effective ◽

Funding Source ◽

First Line ◽

Nice Guidelines ◽

Exercise Ecg ◽

Stable Chest Pain

Abstract Background The National Institute for Health and Care Excellence (NICE) updated their guidance for the management of patients with stable chest pain and recommended that all patients undergo computed tomography coronary angiography (CTCA). This update has sparked a great deal of debate, and was followed by upgrade of CTCA into a Class I indication in the recent ESC guidelines. The cost-effectiveness of using CTCA as first line investigation is still unclear. Purpose To describe the current clinical pathway of patients with stable chest pain presented to outpatient clinics, assess the compliance with the updated NICE guideline, and explore the costs and health outcomes of different non-invasive diagnostic tests in real-world clinical setting. Methods We used data of 4,297 patients who attended chest pain clinics in Oxford between 1 January 2014 and 31 July 2018. Data included clinical presentation (e.g. age and previous cardiovascular conditions), diagnostic tests, outpatient visits, hospitalization, and hospital mortality and was compared between 6 alternative first-line diagnostic tests. Multinomial regressions were performed to estimate the probability of receiving each alternative and the associated cost after adjusting for clinical presentation. A decision tree was developed to describe the clinical pathway for each alternative first-line diagnostic in terms of subsequent diagnostic tests and treatments and to estimate the associated costs and life days. Results The proportion of patients who received CTCA as first line diagnostic test increased from 1% in 2014 to 17% in 2018, while the publication of the updated NICE guidelines in 2016 led to a threefold increase in this proportion. CTCA is less likely to be provided as a first-line diagnostic to patients who are younger age, males, smokers, and have angina, PVD, or diabetes. The standardised rate of hospital admission was the lowest in the exercise ECG cohort (0.35 admissions per 1,000 life-days) followed by the CTCA cohort (0.40 admissions per 1,000 life-days) while the latter cohort had the lowest standardised rate of cardiovascular treatment (2.74% per 1,000 life days). Stress echocardiography and MPS were associated with higher costs compared with CTCA, other ECG, and exercise ECG after adjusting for clinical presentation and days of follow-up. CTCA is the pathway most likely to be cost-effective, even compared to exercise ECG, while the other diagnostic alternatives are dominated (i.e. they cost more for less life-days). Conclusions Currently, the updated NICE guidelines for stable chest pain are implemented only to a fifth of the cases in England. Our findings support existing evidence that CTCA is the most-cost effective first-line diagnostic test for this population. Hopefully, this will inform the debate around the implementation of the guidelines and help commissioning and clinical decision processes worldwide. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Institute of Health Research Oxford Biomedical Research Centre

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Switch Strategy from Direct Aspiration First Pass Technique to Solumbra Improves Technical Outcome in Endovascularly Treated Stroke

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18052670 ◽

2021 ◽

Vol 18 (5) ◽

pp. 2670

Author(s):

Enrico Pampana ◽

Sebastiano Fabiano ◽

Gianluca De Rubeis ◽

Luca Bertaccini ◽

Alessandro Stasolla ◽

...

Keyword(s):

Added Value ◽

Stroke Patients ◽

First Line ◽

Anterior Circulation ◽

First Pass ◽

Procedural Time ◽

The Mean ◽

The Difference ◽

Number Of Passes ◽

Switch Strategy

Background: The major endovascular mechanic thrombectomy (MT) techniques are: Stent-Retriever (SR), aspiration first pass technique (ADAPT) and Solumbra (Aspiration + SR), which are interchangeable (defined as switching strategy (SS)). The purpose of this study is to report the added value of switching from ADAPT to Solumbra in unsuccessful revascularization stroke patients. Methods: This is a retrospective, single center, pragmatic, cohort study. From December 2017 to November 2019, 935 consecutive patients were admitted to the Stroke Unit and 176/935 (18.8%) were eligible for MT. In 135/176 (76.7%) patients, ADAPT was used as the first-line strategy. SS was defined as the difference between first technique adopted and the final technique. Revascularization was evaluated with modified Thrombolysis In Cerebral Infarction (TICI) with success defined as mTICI ≥ 2b. Procedural time (PT) and time to reperfusion (TTR) were recorded. Results: Stroke involved: Anterior circulation in 121/135 (89.6%) patients and posterior circulation in 14/135 (10.4%) patients. ADAPT was the most common first-line technique vs. both SR and Solumbra (135/176 (76.7%) vs. 10/176 (5.7%) vs. 31/176 (17.6%), respectively). In 28/135 (20.7%) patients, the mTICI was ≤ 2a requiring switch to Solumbra. The vessel’s diameter positively predicted SS result (odd ratio (OR) 1.12, confidence of interval (CI) 95% 1.03–1.22; p = 0.006). The mean number of passes before SS was 2.0 ± 1.2. ADAPT to Solumbra improved successful revascularization by 13.3% (107/135 (79.3%) vs. 125/135 (92.6%)). PT was superior for SS comparing with ADAPT (71.1 min (CI 95% 53.2–109.0) vs. 40.0 min (CI 95% 35.0–45.2); p = 0.0004), although, TTR was similar (324.1 min (CI 95% 311.4–387.0) vs. 311.4 min (CI 95% 285.5–338.7); p = 0.23). Conclusion: Successful revascularization was improved by 13.3% after switching form ADAPT to Solumbra (final mTICI ≥ 2b was 92.6%). Vessel’s diameter positively predicted recourse to SS.

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OP0088 INITIATING TNF INHIBITORS IN INFLAMMATORY ARTHRITIS DOES NOT DECREASE THE AVERAGE OPIOID ANALGESIC CONSUMPTION

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.2587 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 58.2-59

Author(s):

O. Palsson ◽

T. Love ◽

J. K. Wallman ◽

M. C. Kapetanovic ◽

P. S. Gunnarsson ◽

...

Keyword(s):

Rheumatoid Arthritis ◽

Psoriatic Arthritis ◽

Inflammatory Arthritis ◽

Opioid Analgesic ◽

Oral Morphine ◽

Undifferentiated Arthritis ◽

First Line ◽

The Mean ◽

Oral Morphine Equivalent ◽

Morphine Equivalent

Background:TNFα-inhibitor (TNFi) therapy is effective in controlling several rheumatic diseases and has been shown to reduce pain in patients with arthritis. Opioids are often prescribed for chronic pain, a common issue in inflammatory joint disease.Objectives:To explore the impact of the initiation of TNFi therapy as a first-line biologic disease-modifying anti-rheumatic drug (DMARD) on the prescription rates of opioids in patients with rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS) and undifferentiated arthritis (UA) in Iceland.Methods:All patients receiving biologic DMARD therapy for rheumatic diseases in Iceland are registered in a nationwide database (ICEBIO). The Icelandic Directorate of Health operates a Prescription Medicines Register that includes over 90% of all drug prescriptions in Iceland. The study group included patients with RA, PsA, AS, and UA registered in ICEBIO and for each of them five randomly selected comparators from the general population matched on age, sex, and calendar time. On February 1st2016 we extracted data on all filled opioid analgesic prescriptions two years before and two years after the date of TNFi initiation.Results:Data from 359 RA, 217 AS, 251 PsA and 113 UA patients and 4700 comparators were collected. In total, 75% of patients compared to 43% of comparators received ≥1 opiate prescription during the study period. The proportion of patients using opioids (regardless of dose) two years prior to TNFi initiation was 41%, increasing to 49% the following year. After TNFi initiation the proportion returned to 40% (Figure 1). Despite this, the mean yearly opiate dose used by the patients followed a rising trajectory throughout the study period (Figure 2). In total, patients were prescribed nearly 6 times more opioids than the comparators, corresponding to a bootstrapped mean (95% CI) dose of 818 (601-1073) mg MED per patient and year compared to 139 (111-171) mg for comparators.Figure 1.Percental distributions of opioid analgesic use by dose (according to dispensed prescriptions) among patients with inflammatory arthritis (A) and matched comparators (B). All doses are oral morphine equivalent dose (MED) in milligrams.Figure 2.Bootstrapped mean oral morphine equivalent dose per person per year for patients with inflammatory arthritis (above) and age and sex matched comparators (below). Box edges represent 25-75thpercentiles and whiskers 95% confidence intervals.Conclusion:Three out of four patients with inflammatory arthritis in Iceland use opioid analgesics in the two years prior to and/or after the initiation of TNFi therapy and the mean doses were significantly higher than in matched comparators. The proportion of patients receiving opioids increased before TNFi therapy and then decreased again to the previous level. The initiation of the first-line TNFi did not reduce opioid consumption by dose at the group level. On the contrary, there was a trend towards increasing doses over time in both patients and comparators, possibly reflecting the development of opiate tolerance.Table 1.Baseline demographic data. Mean ± SD unless specified. * defined from diagnosis to baselAll patientsRheumatoid arthritisPsoriatic arthritisAnkylosing spondylitisUndifferentiated arthritisTotal n (%)940 (100)359 (38)251 (27)217 (23)113 (12)Age (years)49 ± 1453 ± 1449 ± 1343 ± 1344 ± 15Disease duration (years)*7.8 ± 8.58.2 ± 8.27.4 ± 7.88.3 ± 10.26.3 ± 6.6Female58%73%59%34%52%Disclosure of Interests:Olafur Palsson: None declared, Thorvardur Love: None declared, Johan K Wallman Consultant of: Consultant for AbbVie, Celgene, Eli Lilly, Novartis and UCB Pharma., Meliha C Kapetanovic: None declared, Petur S Gunnarsson: None declared, Björn Gudbjornsson Speakers bureau: Novartis and Amgen

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PS01.095: BENIGN ESOPHAGEAL STRICTURE: A RECAP OF OUR EXPERIENCE

Diseases of the Esophagus ◽

10.1093/dote/doy089.ps01.095 ◽

2018 ◽

Vol 31 (Supplement_1) ◽

pp. 76-76

Author(s):

Keat How Teoh ◽

Kelvin Voon ◽

Shyang Yee Lim ◽

Premnath Nagalingam

Keyword(s):

Endoscopic Treatment ◽

Esophageal Stricture ◽

Endoscopic Dilatation ◽

Line Treatment ◽

First Line ◽

Benign Esophageal Stricture ◽

Anastomotic Strictures ◽

Esophageal Strictures ◽

The Mean ◽

First Line Treatment

Abstract Background Caustic injury remains the commonest cause of benign esophageal strictures in Asia. Others include gastroesophageal reflux, iatrogenic, radiation, autoimmune or idiopathic causes. Treatment goals are relief of dysphagia and prevention of recurrence. This study aims to evaluate the experience with benign esophageal stricture in Penang Hospital, a tertiary hospital in Northern region of Malaysia. Methods A retrospective review of 12 patients with benign esophageal strictures between year 2012 - 2017. Results The mean age was 53.5 and two thirds were female. Half of these patients were of Chinese ethnicity while the other half were Indian. The commonest cause was caustic ingestion (41.7%), followed by reflux stricture (25%) and anastomotic stricture (25%). There was one case of dystrophic epidermolysis bullosa. More than half of the patients had complex and multiple strictures. 41.7% of patients had proximal strictures that were located within 20cm from the incisors. Endoscopic dilatation was the first line treatment with either Savary Gilliard or balloon dilators. A total of 97 dilatation sessions were done with a mean dilatation frequency of 2.3 ± 1.5 times for anastomotic strictures, 8 ± 8.2 times for reflux strictures and 8.0 ± 6.6 times for corrosive strictures. The mean dilatation interval was 2.5 ± 1.2 weeks. 58.3% of patients had successful endoscopic treatment. The success rate was higher in non-corrosive stricture (83% vs 40%). There was one dilatation related complication in which the patient had pneumomediastinum without overt mediastinitis. This however, resolved with conservative management. 41.7% of patients had refractory strictures that failed endoscopic dilatation. Surgery including esophagectomy (40%), revision of anastomosis (20%) and gastrostomy (40%) were done for this group of patients. Proximal strictures, complex strictures and multiple strictures were associated with failed endoscopic dilatation (P < 0.05). Conclusion Endoscopic dilatation is the first line treatment for benign esophageal strictures. Surgery is reserved for refractory strictures with failed endoscopic treatment. Predictor scoring systems for refractory stricture and individualized approaches are the key to success. Disclosure All authors have declared no conflicts of interest.

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