A pilot experimental study of oesophageal stenosis after ESD

Czech version

Authors: R. Doležel ¹; O. Ryska ²; Š. Juhás ³; J. Kalvach ¹; B. Walterová ⁴; J. Martínek ⁵
Authors‘ workplace: Chirurgická klinika 2. LF UK a ÚVN Praha ¹; Chirurgické oddělení, Nemocnice Hořovice ²; Ústav živočišné fyziologie a genetiky AV ČR, v. v. i., Liběchov ³; Gymnázium Jana Palacha, Mělník ⁴; Klinika hepatogastroenterologie, Transplantcentrum, IKEM, Praha ⁵
Published in: Gastroent Hepatol 2015; 69(5): 408-412
Category: Clinical and Experimental Gastroenterology: Original Article
doi: https://doi.org/10.14735/amgh2015408

Overview

Endoscopic submucosal dissection (ESD) is a challenging therapeutic method used to remove early neoplasms of the digestive tract. Complete circular ESD in the oesophagus is complicated by an extensive occurrence of postoperative strictures. Such strictures could be prevented using a metallic stent using biomaterial.

Method:
The pilot project was carried out over 12 months, using seven adult miniature pigs (bred in the laboratories of the Czech Academy of Science in Libechov). We used a single-channel endoscope. After tracing the edges and performing submucosal under-puncturing, we made a distal circular incision of the mucosa and then an identical oral circular incision 4–6 cm above it. We created three submucosal tunnels in the caudal direction using punctures and dissection. After completing the circular ESD, we pulled the mucosa outwards and the resection area was covered with oesophageal stents (six uncoated and one coated). Five primarily uncoated stents were coated with biodegradable material (Xe-Derma^®). Three stents were attached to the wall of the oesophagus using endoscopic hemoclips. One week after the procedure, we conducted a control endoscopy followed by autopsy and histological analysis of the resection area.

Results:
All procedures were successfully completed without any major complications. Control endoscopy showed that the stents using biomaterial provide excellent protection to the resection area (i.e. no inflammation, no ulcer or tissue disintegration). Unfortunately, the biomaterial was not positioned optimally in any of the cases, even though the stent had always been deployed and anchored over the resection correctly. In two cases, the biomaterial slid from the stent and the bare-metal stent caused inflammation with fibrotic stenosis of the oesophagus. In animals where no biomaterial was used, the autopsy revealed 1× purulent mediastinitis and 1× para-oesophageal abscess. After one week the stent had migrated into the stomach in 71% (5/7) of the animals. Histological analysis of the resection area covered with biomaterial showed multi-layered re-epithelialization one week after the procedure. Deeper layers showed no signs of inflammation, without dysplasia, or granulomas from foreign cells.

Conclusion:
Biomaterial (Xe-Derma^®) could be a suitable biological covering of the resection area after circular ESD with a positive effect on re-epithelialization and could hypothetically prevent stenosis. Migration of the stent covered with biomaterial has not yet been resolved.

Key words:
circular endoscopic submucosal dissection – complication – oesophageal strictures – submucosal tunnel

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE „uniform requirements“ for biomedical papers.

Submitted:
4. 9. 2015

Accepted:
22. 9. 2015

Sources

1. Hosokawa K, Yoshida S. Recent advances in endoscopic mucosal resection for early gastric cancer. Gan To Kagaku Ryoho 1998; 25(4): 476–483.

2. Rahmi G, Hotayt B, Chaussade S et al. Endoscopic submucosal dissection for superficial rectal tumours: prospective evaluation in France. Endoscopy 2014; 46(8): 670–676. doi: 10.1055/s-0034-1365810.

3. Urban O, Fojtik P, Falt P et al. Krátkodobé výsledky léčby povrchových neoplastických lézí žaludku endoskopickou submukózní disekcí. Gastroent Hepatol 2015; 69(1): 65–69. doi: 10.14735/amgh201565.

4. Coman RM, Gotoda T, Draganov PV et al. Training in endoscopic submucosal dissection. World J Gastrointest Endosc 2013; 5(8): 369–378. doi: 10.4253/wjge.v5.i8.369.

5. Martinek J, Stefanova M, Suchanek S et al. Training of different endoscopic skills on ex-vivo animal model. Simul Healthc 2014; 9(2): 112–119. doi: 10.1097/SIH.0b013e31829be99e.

6. Shi Q, Ju H, Yao LQ et al. Risk factors for postoperative stricture after endoscopic submucosal dissection for superficial esophageal carcinoma. Endoscopy 2014; 46(8): 640–644. doi: 10.1055/s-0034-1365648.

7. Mizuta H, Nishimori I, Kuratani Y et al. Predictive factors for esophageal stenosis after endoscopic submucosal dissection for superficial esophageal cancer. Dis Esophagus 2009; 22(7): 626–631. doi: 10.1111/j.1442-2050.2009.00954.x.

8. Ono S, Fujishiro M, Niimi K et al. Predictors of postoperative stricture after esophageal endoscopic submucosal dissection for superficial squamous cell neoplasms. Endoscopy 2009; 41(8): 661–665. doi: 10.1055/s-0029-1214867.

9. Katada C, Muto M, Manabe T et al. Esophageal stenosis after endoscopic mucosal resection of superficial esophageal lesions. Gastrointest Endosc 2003; 57(2): 165–169.

10. Kobayashi S, Kanai N, Ohki T et al. Prevention of esophageal strictures after endoscopic submucosal dissection. World J Gastroenterol 2014; 20(41): 15098–15109. doi: 10.3748/wjg.v20.i41.15098.

11. Ye LP, Zheng HH, Mao XL et al. Complete circular endoscopic resection using submucosal tunnel technique combined with esophageal stent placement for circumferential superficial esophageal lesions. Surg Endosc 2015. In press.

12. Zajicek R, Matouskova E, Broz L et al. New biological temporary skin cover Xe-Derma® in the treatment of superficial scald burns in children. Burns 2011; 37(2): 333–337. doi: 10.1016/j.burns.2010.07.009.

13. Koster MI, Roop DR. The role of p63 in development and differentiation of the epidermis. J Dermatol Sci 2004; 34(1): 3–9.

14. Vodicka P, Smetana K Jr, Dvoránková B et al. The miniature pig as an animal model in biomedical research. Ann N Y Acad Sci 2005; 1049: 161–171.

15. Martinek J, Suchanek S, Stefanova M et al. Training on an ex vivo animal model improves endoscopic skills: a randomized, single-blind study. Gastrointest Endosc 2011; 74(2): 367–373. doi: 10.1016/j.gie.2011.04.042.

16. Doležel R, Martínek J, Švecová H et al. Efekt učení perorální endoskopické myotomie (POEM) během prvního roku ověřování metody v České republice. Gastroenterol Hepatol 2014; 68(4): 294–298.

17. Uno K, Iijima K, Koike T et al. Useful strategies to prevent severe stricture after endoscopic submucosal dissection for superficial esophageal neoplasm. World J Gastroenterol 2015; 21(23): 7120–7133. doi: 10.3748/wjg.v21.i23.7120.

18. Kataoka M, Anzai S, Shirasaki T et al. Efficacy of short period, low dose oral prednisolone for the prevention of stricture after circumferential endoscopic submucosal dissection (ESD) for esophageal cancer. Endosc Int Open 2015; 3(2): E113–117. doi: 10.1055/s-0034-1390797.

19. Kanai N, Yamato M, Ohki T et al. Fabricated autologous epidermal cell sheets for the prevention of esophageal stricture after circumferential ESD in a porcine model. Gastrointest Endosc 2012; 76(4): 873–881. doi: 10.1016/j.gie.2012.06.017.

20. Ohki T, Yamato M, Ota M et al. Prevention of esophageal stricture after endoscopic submucosal dissection using tissue-engineered cell sheets. Gastroenterology 2012; 143(3): 582–588. doi: 10.1053/j.gastro.2012.04.050.

21. Rieder E, Dunst CM, Martinec D et al. Endoscopic suture fixation of gastrointestinal stents: proof of biomechanical principles and early clinical experience. Endoscopy 2012; 44(12): 1121–1126. doi: 10.1055/s-0032-1325730.

22. Martins B da C, Retes FA, Medrado BF et al. Endoscopic management and prevention of migrated esophageal stents. World J of Gastrointest Endosc 2014; 6(2): 49–54. doi: 10.4253/wjge.v6.i2.49.

23. Hytych V, Horazdovsky P, Stehlik L et al. Our own method of fixation of biodegradable tracheal stent. Bratisl Lek Listy 2015; 116(5): 340–342.

24. Toshniwal J, Zabielski M, Fry LC et al. Combination of the “bear claw” (over-the-scope-clip system) and fully covered stent for the treatment of post-operative anastomotic leak. Endoscopy 2012; 44 (Suppl 2): E288–E289. doi: 10.1055/s-0032-1310033.

25. Kantsevoy SV, Bitner M. Esophageal stent fixation with endoscopic suturing device (with video). Gastrointest Endosc 2012; 76(6): 1251–1255. doi: 10.1016/j.gie.2012.08.003.