Circular Endoscopic Submucosal Dissection Research Articles

Self-help inflatable balloon versus autologous skin-grafting surgery for preventing esophageal stricture after complete circular endoscopic submucosal dissection: a propensity score matching analysis.

The self-help inflatable balloon (SHIB) and autologous skin-grafting surgery (ASGS) were used to prevent stricture after esophageal complete circular endoscopic submucosal dissection (cESD) with promising clinical results. We aim to evaluate which method is more suitable for patients who underwent esophageal cESD. From October 2017 to July 2021, patients whose mucosal defect length were between 30 and 100mm after esophageal cESD were retrospectively reviewed from two prospective studies. They were enrolled once SHIB or ASGS was used as preventive methods to prevent stricture. Propensity score matching (PSM) was used to balance the baseline characteristics between the two groups. Comparisons were made between the two groups, including operation time, the longitudinal length of ulceration, fastingtime, hospitalization days, and the incidence of stricture. A total of 41 patients who met the inclusion criteria were enrolled in the study. The numbers of patients in SHIB group and ASGS group were 25 and 16, respectively. Fifteen patients in each group were selected after performing PSM. The basic baseline characteristics were comparable between the two groups. The stricture rates were 20% (3/15) in SHIB group and 40% (6/15) in ASGS group, while the difference was not statistically significant (p = 0.427). The SHIB group showed significantly shorter operation time, shorter hospitalization days, lower cost, and longer removing balloon/stent time compared with ASGS group (p < 0.001). Comparison of relevant stricture factors between the stricture group and non-stricture group revealed that longer longitudinal length of ulceration (> 60mm) accounted for a higher proportion in stricture groups (p = 0.035). Both the SHIB and ASGS had high efficacy and safety in preventing strictures in patients with mucosal defects no longer than 100mm in length after esophageal cESD. The longitudinal length of ulceration > 60mm was the independent factor for predicting stricture.

Transplantation of acellularized dermis matrix (ADM) plus fully covered metal stent to prevent stricture after circumferential endoscopic submucosal dissection of early esophageal cancer (with video).

Backgroud and study aimsEsophageal stricture is a serious adverse event occurring after circular endoscopic submucosal dissection (ESD) involving the whole esophagus. However, there is still a lack of effectively preventive methods. The main purpose of this study is to evaluate the efficacy of application of acellularized dermis matrix (ADM) for the prevention of post-ESD esophageal stricture. The main objective of this study was to evaluate the use of decellularized dermal matrix (ADM) in the prevention of post-esophageal ESD strictures.Patients and methodsA pilot, single-center, prospective study was conducted. The study enrolled seven patients who had high-risks with extended resection of developing post-ESD esophageal stricture. After undergoing ESD, we attached different size of ADM patches to the mucosal defects using titanium clips then fixed with a metal mesh stent. The stent covered with metal mesh was removed at the median time of 27 days after the endoscopic procedure. Follow-up and repeated outpatient endoscopic screening were performed at appropriate scheduled times.ResultsThe average longitudinal diameter of the resected specimens was 58.3 mm (range 38–90 mm). There were three patients developing strictures postoperatively at a mean time of 87 days (range 42–140). The median number of postoperative endoscopic balloon dilatation (EBD) in patients with stenosis was 2 (range 2–9). There were no deaths during a median follow-up period of 6 moths (range 1–12).ConclusionsThis study was performed to assess the efficacy and safe method of relieving the severity of esophageal stricture after ESD through transplantation of ADM.

Efficacy of hydrocortisone sodium succinate and aluminum phosphate gel for stricture prevention after ≥3/4 circumferential endoscopic submucosal dissection.

ObjectiveEndoscopic submucosal dissection (ESD) is widely used in early-stage esophageal cancer, but the quality of life of patients with postoperative stricture is markedly reduced, requiring long-term repeat, periodic endoscopic balloon dilatation. We evaluated the combination of hydrocortisone sodium succinate and aluminum phosphate gel administered orally for stricture prevention.MethodsWe retrospectively assigned 27 patients who underwent ≥3/4 circular ESD for esophageal superficial squamous cell cancer to one of two groups according to the preventative strategy: endoscopic intralesional steroid injection and systemic steroid (IT+ST group) and oral combination of hydrocortisone sodium succinate and aluminum phosphate gel (OHA group). Stricture rate was compared between the two groups.ResultsThere were six and seven complete and ≥3/4 circular ESD cases, respectively, in the IT+ST group and four and ten cases in the OHA group. Stricture rates in the IT+ST and OHA groups were 53.8% and 7.1%, respectively. Nine patients in each group developed hypokalemia after glucocorticoid administration.ConclusionsOHA is a promising treatment strategy for stricture prevention following large-circumference ESD in patients with early stage esophageal carcinoma.

Autologous Free Skin Transplantation to Prevent Esophageal Stricture After Complete Circular Endoscopic Submucosal Dissection for Superficial Esophageal Neoplasms

Introduction: Endoscopic submucosal dissection (ESD) of circumferential superficial esophageal neoplasms (SENs) was associated with extremely high rate of postoperative stricture, which decreases the patient’s quality of life substantially. So far, no standard guideline for preventing esophageal stricture in patients after ESD has been established. We aimed to assess the effectiveness and safety of endoscopic transplantation of autologous free skin in preventing stricture formation after circumferential ESD. Methods: A total of 8 patients who underwent circumferential ESD were included in the study. After undergoing ESD, autologous free skin harvested from the right outer thigh of the patient was sewed into a “oversleeve-like” skin and then covered on the outside of a fully-covered esophageal stent. Finally, the stent was placed at the location of the artificial ulcer of esophagus. The stent was removed 4 weeks after the procedure. The patients were followed up with endoscopy at scheduled times. Results: Complete circular ESD and autologous free skin transplantation were successfully performed in all patients. The mean longitudinal diameter of the resected specimens was 98.8 mm (range 70 - 160 mm). The skin grafts grew well and biopsy-proven squamous epithelium with hyperkeratosis at the site of transplant. Five patients (5 / 8, 62.5 %) didn’t experience dysphagia and stricture with a mean follow-up of 4.9 months (range 3 - 8 months). No complications including perforation, bleeding, wound infection, and stent migration were observed during the follow-up. Conclusion: Endoscopic transplantation of free skin could be a safe and effective way of preventing esophageal stricture after circumferential ESD. Long-term follow-up and experience with a large series are needed to further evaluation of this method.352_A Figure 1. Clinical outcomes for 8 patients with early esophageal cancer after circumferential ESD.352_B Figure 2. ESD resulted in a completely circumferential resection. B, The stent was placed on the esophageal ulcer.352_C Figure 3. At endoscopic follow-up 6 months after ESD, the skin graft grew well without any evidence of stricture. A, C: White-light view. B, D: Iodine stain view.

Treatment of long-segment Barrett\u2019s adenocarcinoma by complete circular endoscopic submucosal dissection: a case report

BackgroundWe present the first description of en bloc endoscopic submucosal dissection (ESD) for total circumferential Barrett’s adenocarcinoma, predominantly of the long-segment Barrett’s esophagus (LSBE), with a 2-year follow-up and management strategies for esophageal stricture prevention.Case presentationA 59-year-old man was diagnosed with LSBE and Barrett’s adenocarcinoma by esophagogastroduodenoscopy (EGD). A 55-mm-long circumferential tumor was completely resected by ESD. Histopathology revealed a well-differentiated adenocarcinoma within the LSBE superficial muscularis mucosa. For post-ESD stricture prevention, the patient underwent an endoscopic triamcinolone injection administration, oral prednisolone administration, and preemptive endoscopic balloon dilatation. Two years later, there is no evidence of esophageal stricture or recurrence.ConclusionsESD appears to be a safe, effective option for total circumferential Barrett’s adenocarcinoma in LSBE.

Efficacy of short period, low dose oral prednisolone for the prevention of stricture after circumferential endoscopic submucosal dissection (ESD) for esophageal cancer.

Background and aims: Endoscopic submucosal dissection (ESD) was developed in Japan and has been performed on many patients with early stage esophageal cancer; however quality of life in patients with postoperative stricture is drastically decreased and repeat, periodic endoscopic balloon dilatation (EBD) is usually required over long periods. In this study, we evaluate the efficacy of short period, low dose oral prednisolone in controlling post-procedural esophageal stricture. Patients and methods: In total, 33 patients who underwent semicircular or complete circular ESD for esophageal superficial squamous cell carcinoma were included in this study. They were divided into two groups: those who underwent large-circumference ESD with no preventative treatment for stricture (ESD alone group) and those who received systemic steroid treatment for stricture (oral prednisolone group). We compared the two groups in terms of stricture rate and total number of EBD sessions. The ESD alone group underwent no preventative treatment. The oral prednisolone group started with 30 mg/day prednisolone on the second day post-ESD, and continued with a gradually tapering prednisolone dose, finally discontinuing systemic steroid administration 3 weeks later. Results: The stricture rate after ESD was significantly lower in the oral prednisolone group (3 of 17 patients; 17.6 %) than in the ESD alone group (11 of 16 patients; 68.7 %) (P < 0.01). The number of EBD sessions was significantly lower in the oral prednisolone group than in the ESD alone group (median 4.6, range 2 – 10 vs. median 8.1, range 1 – 18; P < 0.01). Conclusion: Short period, low dose oral prednisolone showed promising results for the prevention of stricture after ESD for early stage esophageal cancers.

When is pre-emptive treatment necessary after endoscopic mucosal resection of early esophageal neoplasm?

When is pre-emptive treatment necessary after endoscopic mucosal resection of early esophageal neoplasm?

Sp608 Successful Mucosal Transplantation from Stomach to Esophagus for Stricture Prevention after Widespread Circular Endoscopic Submucosal Dissection (ESD) For Early Esophageal Squamous Cell Carcinoma - Report of a First Case in Man with 1 1/2 Year Transplant Survival

Secondary stricture formation is the major drawback for resections >3 cm or more than 75% of the esophageal circumference at esophageal ESD. In March 2011 we embarked on animal experiments regarding esophageal resection and re-transplantation of esophageal and gastric mucosal patches in pigs under an approved protocol (NLVL No: 33-42502-06/1151) for stricture prevention. CASE REPORT: A 72 y old man with swallowing difficulty (DG1); tabacco use of 20 py until >15 y ago. Prior rectal resection with sigma anus praeter for a T2 distal rectal cancer. EGD: Suspicion of early squamous cell cancer (Paris IIa; EUS UT1a, m, N0), >75% circum-ferential tumor spread within the cervical esophagus and upper sphincter area (17-25 cm aborally). Biopsy: SC HG-IEN. On April 13, 2011 we performed an EGD under general anesthesia with tracheal intubation with first tubular ESD over 10 cm from the lower hypopharynx through the UES from 17-27 cm followed by a 9x4 cm ESD in the gastric antrum. The healthy gastric specimen retrieved was cut longitudinally into 3 mucosal stripes that were attached to the denuded esophageal muscular layer by means of hemoclips. The stripes were gently pressed against the wall by a non-covered self-expanding metal stent with the intent to allow also a luminal nutrition of the specimen. The sphincter area of 1.5 cm length had to be spared. The esophageal specimen showed a non-invasive low horny early squamous cell cancer (pT1a G2 L-, V-) and curative resection (R0; invasion depth of lamina propria max. 150 microns). Stent removal was performed at day 20 and was cumbersome due to local mucosal hyperplasia. However, multiple islets of gastric mucosa had successfully grown at the esophageal resection site. The patient was discharged on day 24 and regularly seen as outpatient. We observed a stepwise circular spread out of the reddish layer over an area of 5-6 cm within the next 6 months. Stenosis was successfully prevented. Biopsy proved antral HP-negative mucosa. 1 1/2 years later the patient is free of complaints. This first case of a successful gastro-esophageal endoscopic mucosal transplant with one year follow-up after wide- spread ESD in the esophagus for an early squamous cell cancer opens a new perspective for systematic research in this field.

Successful mucosal transplantation from stomach to esophagus for stricture prevention after widespread circular endoscopic submucosal dissection (ESD) for early esophageal squamous cell carcinoma – report of a first case in man with 1 year transplant survival after preliminary animal experiments in the pig

ESD in the esophagus is an expert technique for ‘en bloc’ resection of mucosal cancers >2cm in size. I can provide a quasi-surgical specimen and significantly reduces the risk of local recurrence compared to piecemeal EMR. However, secondary stricture formation is the major drawback for resections >3cm and of more than 75% of the esophageal circumference. Multiple bouginage sessions or temporary stent placement may be required limiting the QoL. Experimental approches include transplantation of buccal or dermal cell grafts as well as systemic and local steroid applications. However, clinical experience is very limited so far. Since march 2011 be had been performing animal experiments concerning esophageal resection and re-transplantation of esophageal and gastric mucosal patches in pigs under an approved protocol (NLVL No: 33–42502–06/1151) with first preliminary but encouraging results when the following clinical presented. Case report: A 72 y male pat. with swallowing difficulty; tabacco use of 20 py until >15y ago. Prior rectal resection with sigma anus praeter for a T2 distal rectal cancer. EGD: Suspicion of early squamous cell cancer (Paris IIa; EUS UT1a, m, N0), >75% circum-ferential superficial tumor spread within the cervical esophagus and upper sphincter area (17–25cm aborally). Biopsy: SC HG-IEN. Discussion of the different treatment options in our interdisciplinary tumor board and with the patient: tubular endoscopic resection alone with 80–100% stricture probability, thermal ablation, radical surgery, primary chemoradiation or an experimental approach as compassionate use with primary ESD in the esophagus and secondary gastro-esophageal mucosal patch transplantation. On April 13, 2011 we performed an EGD under general anesthesia with tracheal intubation with first tubular ESD over 10cm from the lower hypopharynx through the UES from 17–27cm followed by a 9×4cm ESD in the gastric antrum. The healthy gastric specimen prelieved was cut longitudinally into 3 mucosal stripes which were attached to the denuded esophageal muscular layer by means of hemoclips. The specimen were gently pressed against the wall by a non-covered self-expanding metal stent to allow luminal and vascular nutrition of the specimen. The sphincter area of 1.5cm length had to be spared in order to not compress the lower larynx with the stent and to avoid unsupportable pain for the patient. After a control the following day the patient could be extubated. The esophageal specimen showed a non-invasive low horny early squamous cell cancer (pT1a G2 L-, V-) and and curative resection (R0; invasion depth of lamina propria max. 150 microns). Stent removal was performed at day 20 pp and was cumbersome due to local mucosal hyperplasia. However, multiple islets of gastric mucosa had successfully grown at the esophageal resection site. The patient was discharged on day 24 and regulary seen as outpatient. We observed a stepwise circular spread out of the reddish layer over an area of 5–6cm within the next 6 month and successful prevention of stenosis. Biopsy proved antral HP-negative mucosa. Unfortunately a 1–1.5cm non-transplant covered segment in the sphincter area showed a repetive tendency to stricture formation serving quasi as ‘natural’ control and requiring multiple ambulatory bouginage treatments but allowing a (semi-) solid diet without restrictions for most food products (DG1). Conclusions: The so far unique case of a gastro-esophageal endoscopic mucosal transplant with one year follow-up after wide-spread ESD in the esophagus for an early squamous cell cancer opens a new perspective for systematic research in this field.

Management of esophageal stricture after complete circular endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma

BackgroundEndoscopic submucosal dissection (ESD) permits removal of esophageal epithelial neoplasms en bloc, but is associated with esophageal stenosis, particularly when ESD involves the entire circumference of the esophageal lumen. We examined the effectiveness of systemic steroid administration for control of postprocedural esophageal stricture after complete circular ESD.MethodsSeven patients who underwent wholly circumferential ESD for superficially extended esophageal squamous cell carcinoma were enrolled in this study. In 3 patients, prophylactic endoscopic balloon dilatation (EBD) was started on the third post-ESD day and was performed twice a week for 8 weeks. In 4 patients, oral prednisolone was started with 30 mg daily on the third post-ESD day, tapered gradually (daily 30, 30, 25, 25, 20, 15, 10, 5 mg for 7 days each), and then discontinued at 8 weeks. EBD was used as needed whenever patients complained of dysphagia.ResultsEn bloc ESD with tumor-free margins was safely achieved in all cases. Patients in the prophylactic EBD group required a mean of 32.7 EBD sessions; the postprocedural stricture was dilated up to 18 mm in diameter in these patients. On the other hand, systemic steroid administration substantially reduced or eliminated the need for EBD. Corticosteroid therapy was not associated with any adverse events. Post-ESD esophageal stricture after complete circular ESD was persistent, requiring multiple EBD sessions.ConclusionsUse of oral prednisolone administration may be an effective treatment strategy for reducing post-ESD esophageal stricture after complete circular ESD.

Usefulness of oral prednisolone in the treatment of esophageal stricture after endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma

Endoscopic submucosal dissection (ESD) permits en bloc removal of superficial esophageal squamous cell carcinoma. However, postprocedure stricture is common after ESD for extensive tumors, and multiple endoscopic balloon dilation (EBD) is required for recalcitrant cases. To evaluate the effectiveness of oral prednisolone in controlling postprocedure esophageal stricture. Retrospective study. Endoscopy department at a university hospital. Patients who underwent complete circular or semicircular ESD for esophageal squamous cell carcinoma involving more than three fourths of the lumen were treated with either pre-emptive EBD or oral prednisolone. Preemptive EBD was started on the third day post-ESD and continued twice weekly for 8 weeks. Oral prednisolone was started at 30 mg/day on the third day post-ESD , tapered gradually, and then discontinued 8 weeks later. An additional EBD was performed on demand in both groups whenever dysphagia appeared. The incidence of esophageal stricture and number of EBD sessions required to relieve dysphagia. Stricture at 3 months after ESD was found in 7 of 22 patients in the preemptive EBD group but only 1 of 19 in the oral prednisolone group (P < .05). The average number of EBD sessions required was 15.6 in the preemptive EBD group and 1.7 in the oral prednisolone group (P < .0001). After complete circular ESD, 32.7 EBD sessions were needed on average in the preemptive EBD group, whereas fewer were needed in the oral prednisolone group (P < .05). Nonrandomized study. Post-ESD esophageal strictures were persistent even if treated preemptively with multiple EBD sessions, but oral prednisolone may offer a useful preventive option.