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Tang J, Ye S, Ji X, Liu F, Li Z. Deployment of carboxymethyl cellulose sheets to prevent esophageal stricture after full circumferential endoscopic submucosal dissection: A porcine model. Dig Endosc 2018; 30:608-615. [PMID: 29617545 DOI: 10.1111/den.13070] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 03/30/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM Esophageal stricture is a serious adverse event secondary to extensive endoscopic submucosal dissection (ESD). The present study aimed to investigate the efficacy of carboxymethyl cellulose (CMC) sheets for the prevention of esophageal stricture after full circumferential ESD in an animal model. METHODS Fourteen porcine models were randomized into a control group (n = 7) and a CMC group (n = 7). Five-centimeter-long circumferential esophageal ESD was carried out at a distance of 40 to 45 cm from the incisors in all models. In the CMC group, CMC sheets were placed over the mucosal defect completely after ESD, whereas the control group underwent routine ESD only. Endoscopic examination was conducted after the first and second week post-ESD. Esophageal specimens were harvested during post-mortem and were evaluated for macroscopic and histological appearance. Blood serum levels of four pro-inflammatory or profibrotic cytokines were measured quantitatively. RESULTS The CMC group had better food tolerability during the second week post-ESD. The CMC group showed a significantly lower esophageal mucosal stricture rate compared to the control group. Histological assessments showed less fibrosis in the submucosal layer, milder damage to the muscularis propria, and enhanced re-epithelization in the CMC group. Serum transforming growth factor beta 1 levels were significantly lower in the CMC group post-ESD. CONCLUSION Deployment of CMC sheets on the mucosal defect appears to be a promising method for preventing esophageal strictures after extensive ESD.
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Affiliation(s)
- Jian Tang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Shufang Ye
- Department of Gastroenterology, Lishui People's Hospital, Lishui, China
| | - Xueliang Ji
- Department of Gastroenterology, Lishui People's Hospital, Lishui, China
| | - Feng Liu
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhaoshen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
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Mizumoto T, Hiyama T, Oka S, Yorita N, Kuroki K, Kurihara M, Yoshifuku Y, Sanomura Y, Urabe Y, Murakami Y, Arihiro K, Tanaka S, Chayama K. Curative Criteria After Endoscopic Resection for Superficial Esophageal Squamous Cell Carcinomas. Dig Dis Sci 2018; 63:1605-1612. [PMID: 29564670 DOI: 10.1007/s10620-018-5029-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2017] [Accepted: 03/15/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND According to the Japanese Esophageal Society (JES) guidelines, risk factors for lymph node (LN) metastasis in the muscularis mucosa (MM)/submucosa to a depth of up to 200 μm (SM1) in cases of esophageal squamous cell carcinomas (ESCCs) include the presence of lymphatic invasion (ly), venous invasion (v), infiltration pattern (INF)c, and SM1. The long-term prognoses of these patients are unclear, and there are very few reports on the validation of the curative criteria for MM/SM1 ESCCs. AIMS To examine the long-term prognoses of these patients and the risk factors for LN metastasis of MM/SM1 ESCCs after endoscopic resection (ER). METHODS This study included patients with MM/SM1 ESCCs who underwent ER at Hiroshima University Hospital from December 1990 to November 2016. We evaluated the clinicopathological characteristics of 98 patients and overall survival, disease-specific survival, recurrence-free survival, and recurrence rates in the e-curative and non-e-curative groups. RESULTS The mean observation period was 75 months. There was no significant difference in disease-specific survival rate between the e-curative and non-e-curative groups (100 vs. 98%). There was no significant difference in disease-specific survival rates between the groups (100 vs. 98%). In contrast, the LN recurrence-free survival rate in patients with INFa, ly(-), and v(-) was significantly higher than that in patients with INFb/c, ly(+), or v(+) (100 and 87%, P < 0.05). CONCLUSION Contrary to the JES guidelines, our findings suggest that new criteria (MM/SM1, INFa, negative vertical margin (VM0), ly[-], and v[-]) may be associated with curative ER without additional treatment.
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Affiliation(s)
- T Mizumoto
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - T Hiyama
- Health Service Center, Hiroshima University, 1-7-1 Kagamiyama, Higashihiroshima, 739-8514, Japan.
| | - S Oka
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - N Yorita
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - K Kuroki
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - M Kurihara
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Y Yoshifuku
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
| | - Y Sanomura
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Y Urabe
- Department of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Y Murakami
- Department of Radiation Oncology, Hiroshima University Graduate School of Biomedical Sciences, Hiroshima, Japan
| | - K Arihiro
- Department of Anatomical Pathology, Hiroshima University Hospital, Hiroshima, Japan
| | - S Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - K Chayama
- Department of Gastroenterology and Metabolism, Hiroshima University Hospital, Hiroshima, Japan
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Wang WP, Ni PZ, Yang JL, Wu JC, Yang YS, Chen LQ. Esophagectomy after endoscopic submucosal dissection for esophageal carcinoma. J Thorac Dis 2018; 10:3253-3261. [PMID: 30069321 DOI: 10.21037/jtd.2018.05.143] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Endoscopic submucosal dissection (ESD) has been used to treat early stage esophageal cancer, but reports about additional esophagectomy after ESD and postoperative outcomes are lacking. Complete removal of cancer tissue together with lymph nodes was the advantage of esophagectomy; however, invasiveness, organ loss, postoperative complications, and worse postoperative quality of life were serious disadvantages. The purpose of this study was to find the clear indication of additional esophagectomy after ESD, and help the other patients avoid excessive surgery. Methods We reviewed the clinicopathologic data and outcomes consecutive patients who had esophageal cancer confirmed by endoscopic biopsy and who were treated with ESD and subsequent esophagectomy between October 2011 and December 2016 in our department. The esophagectomy necessity following ESD was defined and the groups with necessity (+) vs. (-) were compared retrospectively. The esophagectomy necessity outcomes were retrospectively analyzed to judge whether the surgery option was correct. Results Total 214 patients with esophageal and esophagogastric cancer have undergone ESD treatment in our center, of which 32 patients (23 men and 9 women; mean age, 60±8 years) ultimately required esophagectomy after ESD. All patients had complete resection (R0) from esophagectomy. Postoperative TNM staging included TisN0M0 (6 patients), T1aN0M0 (6 patients), T1bN0M0 (18 patients), T1bN1M0 (1 patient), and T2N3M0 (1 patient). Necessity of esophagectomy after ESD was associated with residual margin status. There was a significant difference in ESD specimen margin status between the esophagectomy necessity (+) vs. (-) groups (positive/negative margin: 8/3 vs. 2/9 patients; P=0.03). Esophagectomy should be delayed at least 30 days after ESD to enable resolution of esophageal edema (P=0.017) (206±68 vs. 163±56 mL, P=0.057). Median follow-up was 16.8 months (range, 11.2-54.5 months); 3 patients were lost to follow-up (9%) and 1 patient died of metastasis after esophagectomy. All other patients were alive with excellent postoperative disease-free survival. Conclusions Indications for esophagectomy after ESD include ESD failure, cancer recurrence, esophageal rupture, esophageal stricture refractory to endoscopic dilation, and residual tumor at the ESD specimen margin. Stage T1b alone is not an indication for esophagectomy. According to our study, we recommend that esophagectomy should be delayed ≥30 dafter ESD unless urgent esophagectomy is indicated.
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Affiliation(s)
- Wen-Ping Wang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Peng-Zhi Ni
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jin-Lin Yang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jun-Chao Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yu-Shang Yang
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Long-Qi Chen
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu 610041, China
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Han Y, Guo J, Sun S, Wu W, Wang S, Ge N, Liu X, Wang G, Wang S. Acellular dermal matrix for esophageal stricture prevention after endoscopic submucosal dissection in a porcine model. Gastrointest Endosc 2017; 86:1160-1167. [PMID: 28396274 DOI: 10.1016/j.gie.2017.02.038] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Accepted: 02/23/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) is considered an effective treatment for early esophageal cancer and precancerous lesions. Esophageal stenosis is closely associated with quasi-circumferential ESD. We examined whether post-ESD esophageal stricture can be prevented by grafting an acellular dermal matrix (ADM) membrane. METHODS Fourteen Bama miniature pigs were randomly divided into an ADM group (n = 7) and a control group (n = 7). Semicircumferential ESD was performed at the distal esophagus in all animals, and in the ADM group an ADM patch graft was placed at the resection site and secured innovatively with metal clips. Animals in the control group underwent ESD only. Endoscopy was performed at 3 days, 1 week, 2 weeks, and 4 weeks post-ESD, and fluoroscopy was performed at 4 weeks for assessment of the degree of stenosis, after which the remodeled esophageal tissues were excised for histologic analysis. RESULTS No animals in the ADM group developed clinically significant esophageal stenosis, whereas 42.8% (3/7) in the control group did. The degree of stenosis was severe in the control group (39.8% vs 17.2%, respectively; P = .01). Animals in the ADM group had less feeding difficulty and lost less weight (-.9 kg vs -4.1 kg, respectively; P = .007). Histologically, complete mucosal epithelium, slight local inflammation, and organized collagenous fibers were observed in the ADM group. CONCLUSIONS ADM patch graft appears, after short-term observation, to be a potentially useful new treatment strategy for prevention of esophageal stricture after ESD. A metal clip fixation technique is effective for endoscopic graft attachment.
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Affiliation(s)
- Ye Han
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jintao Guo
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, China
| | - Siyu Sun
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, China
| | - Weichao Wu
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, China
| | - Sheng Wang
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, China
| | - Nan Ge
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xiang Liu
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, China
| | - Guoxin Wang
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, China
| | - Shupeng Wang
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, China
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Shimamura Y, Ikeya T, Marcon N, Mosko JD. Endoscopic diagnosis and treatment of early esophageal squamous neoplasia. World J Gastrointest Endosc 2017; 9:438-447. [PMID: 28979708 PMCID: PMC5605343 DOI: 10.4253/wjge.v9.i9.438] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/14/2017] [Accepted: 08/17/2017] [Indexed: 02/06/2023] Open
Abstract
Esophageal cancer is one of the leading causes of cancer-related death and is associated with high morbidity and mortality. It carries a poor prognosis as more than half of patients present with advanced and unresectable disease. One contributing factor is the increased risk of lymph node metastases at early stages of disease. As such, it is essential to detect squamous cell neoplasia (SCN) at an early stage. In order to risk stratify lesions, endoscopists must be able to perform image enhanced endoscopy including magnification and Lugol’s chromoendoscopy. The assessment of both the horizontal extent and depth of any lesion is also of utmost importance prior to treatment. Endoscopic mucosal resection and submucosal dissection remain the standard of care with literature supportive their respective use. Radiofrequency ablation and other endoscopic treatments are currently available although should not be considered first line at this time. Our objective is to review the current options for the endoscopic diagnosis and treatment of esophageal SCN.
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Affiliation(s)
- Yuto Shimamura
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON M5B1W8, Canada
| | - Takashi Ikeya
- Department of Gastroenterology, St. Luke’s International Hospital, Tokyo 104-8560, Japan
| | - Norman Marcon
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON M5B1W8, Canada
| | - Jeffrey D Mosko
- Division of Gastroenterology, St. Michael’s Hospital, University of Toronto, Toronto, ON M5B1W8, Canada
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Raghu Subramanian C, Triadafilopoulos G. Diagnosis and therapy of esophageal squamous cell dysplasia and early esophageal squamous cell cancer. Gastroenterol Rep (Oxf) 2017. [DOI: 10.1093/gastro/gox022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Single Locoregional Triamcinolone Injection Immediately After Esophageal Endoscopic Submucosal Dissection Prevents Stricture Formation. Clin Transl Gastroenterol 2017; 8:e75. [PMID: 28230852 PMCID: PMC5387750 DOI: 10.1038/ctg.2017.5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 01/09/2017] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES Although endoscopic submucosal dissection (ESD) is an efficient treatment for superficial esophageal cancer, it is associated with stricture formation after wide-circumference resection that leads to a low quality of life. Although locoregional steroid injections prevent stricture formation, a randomized comparative study did not report any advantages associated with steroid injection. We evaluated the prophylactic efficacy of a single locoregional triamcinolone injection for stricture formation after esophageal ESD. METHODS This was a retrospective matched case-control study using propensity score matching (PSM). Between April 2006 and July 2015, a total of 602 patients with superficial esophageal neoplasia underwent ESD. Among them, 189 patients with mucosal defects that spanned more than 2/3 of the esophageal circumference were included. After exclusion, 150 patients were enrolled. Triamcinolone acetonide (80 mg) was injected into the residual submucosal layer of the resected region immediately after ESD. PSM was performed to reduce the effects of selection bias for steroid injection. The primary outcome was the incidence of stricture formation. The secondary outcome was the number of balloon dilatation procedures required to resolve the stricture formation. RESULTS Thirty-seven patients, with and without triamcinolone injection each, were matched after PSM. The incidence of stricture formation decreased from 45.9% (17/37) without triamcinolone injection to 18.9% (7/37) with triamcinolone injection (p=0.016). After matching, the mean number of balloon dilatation procedures required also decreased from 2.8±4.6 to 0.6±1.5 times (P<0.01). CONCLUSIONS A single locoregional triamcinolone injection efficiently prevented stricture formation after esophageal ESD.
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Nagami Y, Shiba M, Tominaga K, Ominami M, Fukunaga S, Sugimori S, Tanaka F, Kamata N, Tanigawa T, Yamagami H, Watanabe T, Fujiwara Y, Arakawa T. Hybrid therapy with locoregional steroid injection and polyglycolic acid sheets to prevent stricture after esophageal endoscopic submucosal dissection. Endosc Int Open 2016; 4:E1017-22. [PMID: 27652294 PMCID: PMC5025303 DOI: 10.1055/s-0042-111906] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 06/13/2016] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND STUDY AIM The incidence of stricture formation caused by endoscopic submucosal dissection (ESD) for widespread lesions is high, and stricture formation can reduce quality of life. We evaluated the prophylactic efficacy of hybrid therapy using a locoregional steroid injection and polyglycolic acid (PGA) sheets with fibrin glue to prevent stricture formation after esophageal ESD in high risk patients in whom we predicted stricture formation would be difficult to prevent with a single prophylactic steroid injection. METHODS Ten patients who underwent esophageal ESD were enrolled (entire-circumference: n = 6; sub-circumference, more than 5/6 of the circumference: n = 4). A single locoregional steroid injection and PGA sheets with fibrin glue were used after ESD. We evaluated the incidence of stricture formation, the number of endoscopic balloon dilation (EBD) procedures needed to treat the stricture formation, and adverse events of the therapy. RESULTS Esophageal stricture formation occurred in 50.0 % of patients (5/10) (median EBD sessions 0.5, range 0 - 16). Subanalysis showed that stricture formation occurred in 37.5 % of patients (3/8) excluded the lesions located near a previous scar from ESD or surgical anastomosis site (median EBD sessions 0, range 0 - 4). CONCLUSION Hybrid therapy using a locoregional steroid injection and PGA sheets with fibrin glue may have the potential to prevent esophageal stricture formation after esophageal ESD in high risk patients.
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Affiliation(s)
- Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masatsugu Shiba
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kazunari Tominaga
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan,Corresponding author Kazunari Tominaga, MD, PhD Department of GastroenterologyOsaka City University Graduate School of Medicine1-4-3AsahimachiAbeno-kuOsaka545-8585Japan+81-6-66453813
| | - Masaki Ominami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Shusei Fukunaga
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Satoshi Sugimori
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Fumio Tanaka
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Noriko Kamata
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tetsuya Tanigawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hirokazu Yamagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Toshio Watanabe
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Yasuhiro Fujiwara
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Tetsuo Arakawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
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