Effectiveness of fibrin sealant as hemostatic technique in accelerating ESD-induced ulcer healing: a retrospective study

Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review

ESGE suggests conventional endoscopic submucosal dissection (ESD; marking and mucosal incision followed by circumferential incision and stepwise submucosal dissection) for most esophageal and gastric lesions. ESGE suggests tunneling ESD for esophageal lesions involving more than two-thirds of the esophageal circumference. ESGE recommends the pocket-creation method for colorectal ESD, at least if traction devices are not used. The use of dedicated ESD knives with size adequate to the location/thickness of the gastrointestinal wall is recommended. It is suggested that isotonic saline or viscous solutions can be used for submucosal injection. ESGE recommends traction methods in esophageal and colorectal ESD and in selected gastric lesions. After gastric ESD, coagulation of visible vessels is recommended, and post-procedural high dose proton pump inhibitor (PPI) (or vonoprazan). ESGE recommends against routine closure of the ESD defect, except in duodenal ESD. ESGE recommends corticosteroids after resection of  > 50 % of the esophageal circumference. The use of carbon dioxide when performing ESD is recommended. ESGE recommends against the performance of second-look endoscopy after ESD. ESGE recommends endoscopy/colonoscopy in the case of significant bleeding (hemodynamic instability, drop in hemoglobin > 2 g/dL, severe ongoing bleeding) to perform endoscopic hemostasis with thermal methods or clipping; hemostatic powders represent rescue therapies. ESGE recommends closure of immediate perforations with clips (through-the-scope or cap-mounted, depending on the size and shape of the perforation), as soon as possible but ideally after securing a good plane for further dissection.

Efficacy of local hemostatic agents after endoscopic submucosal dissection: a meta-analysis

INTRODUCTION

Topical hemostatic agents have been used to reduce bleeding rates after endoscopic submucosal dissection (ESD) for gastric cancer. However, to date, no review has summarized evidence on their efficacy.

MATERIAL AND METHODS

PubMed, Embase, ScienceDirect, CENTRAL, and Google Scholar were searched for studies comparing bleeding rates after ESD with and without local hemostatic agents.

RESULTS

Eleven studies were included. The studies used polyglycolic acid (PGA) sheets and fibrin glue, fibrin glue, oxidized regenerated cellulose, polysaccharide hemostatic powder, or polyethylene oxide adhesive. Meta-analysis revealed a statistically significant reduction in the risk of delayed bleeding with the use of PGA sheets & fibrin glue (six studies; RR: 0.35 95% CI: 0.20, 0.63 p = 0.0005). However, meta-analysis of two studies showed no difference in the risk of bleeding based on the use of fibrin glue (RR: 0.44 95% CI: 0.03, 7.17 p = 0.56). Scarce data were available for the remaining hemostatic agents.

CONCLUSION

A large number of different hemostatic agents have been used to reduce the risk of bleeding after ESD for gastric cancer. Observational studies indicate that the use of PGA with fibrin glue could reduce the risk of bleeding after ESD. However, evidence for other agents was too scarce to derive conclusions.

Porcine Fibrin Sealant Promotes Skin Wound Healing in Rats

Objective

Fibrin sealant (FS) is widely used for skin wound healing, but data on porcine FS (PFS), a new type of FS, are limited. This study investigated the effects and potential mechanisms of porcine fibrin sealant (PFS) on skin wound healing in rats. Methods. Traumatic rats were randomly divided into three groups: control, PFS, and medical Vaseline. The wound area and wound index of the rats were measured within 14 days after surgery. Hematoxylin-eosin (H&E) staining and Masson staining were used to observe the pathological images and collagen formation on the wounded skin, respectively. To investigate the healing mechanisms, the enzyme-linked immunosorbent assay (ELISA) was used to detect platelet endothelial cell adhesion molecule-1 (CD31) and cluster of differentiation 34 (CD34) expression in the wounded skin. Additionally, quantitative real-time PCR (qRT-PCR) was used to evaluate the mRNA levels of the vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF), and epidermal growth factor (EGF), and transforming growth factor-β1 (TGF-β1). Meanwhile, TGF-β1 protein expression was assessed by Western blot analysis.

Results

Compared with the control group, both PFS and medical Vaseline treatment significantly reduced the wounded area and increased the wound closure rate. H&E staining showed that the cells in the PFS group proliferated rapidly, and the epidermis and dermis were thickened to some extent with a clear epidermal cell structure. Moreover, PFS promoted the formation of collagen and significantly increased the levels of CD31 and CD34 and the growth factors in the skin tissues of the traumatic rats.

Conclusion

PFS effectively promoted skin wound healing, especially in tissue formation, reepithelialization, angiogenesis, and collagen deposition, in traumatic rat models. This study provides a new strategy and scientific foundation for PFS application in skin wound healing.

Endoscopic Delivery of Polymers Reduces Delayed Bleeding after Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis

New endoscopic approaches for the prevention of delayed bleeding (DB) after gastric endoscopic submucosal dissection (ESD) have been reported in recent years, and endoscopic delivery of biodegradable polymers for iatrogenic ulcer hemostasis and coverage has emerged as one of the most promising techniques for post-ESD management. However, the comparative efficacy of these techniques remains uncertain. We performed a systematic search of multiple databases up to May 2022 to identify studies reporting DB rates as outcomes in patients undergoing gastric ESD who were treated with subsequent endoscopic management, including endoscopic closure (clip-based methods and suturing), PGA sheet tissue shielding, and hemostatic powder/gel spray (including polymeric sealants and other adhesives). The risk ratios (RRs) of delayed bleeding in treatment groups and control groups were pooled, and the Bayesian framework was used to perform a network meta-analysis (NMA). Among these studies, 16 head-to-head comparisons that covered 2742 lesions were included in the NMA. Tissue shielding using PGA sheets significantly reduced the risk of DB by nearly two thirds in high-risk patients, while hemostatic spray systems, primarily polymer-based, reduced DB in low-risk patients nine-fold. Researchers should recognize the essential role of polymers in the management of ESD-induced ulcers, and develop and validate clinical application strategies for promising materials.

The future of endoscopic resection for early gastric cancer

Endoscopic resection for early gastric cancer is recommended when the risk of lymph node metastasis is negligible and should be performed through submucosal dissection due to well-established short- and long-term results. To overcome technical difficulties and decrease adverse events some techniques have been studied. This review outlines current strategies for improving patient selection and highlights innovative techniques that help minimize adverse events. Moreover, we discuss how to improve management after curative and noncurative resections.

Vonoprazan vs lansoprazole for the treatment of artificial gastric ulcer after endoscopic submucosal dissection: a prospective randomized comparative study

Vonoprazan is a potent inhibitor of gastric acid secretion and may have better response than proton pump inhibitors (PPIs) in the treatment of endoscopic submucosal dissection induced artificial ulcers. However, reported outcomes remain controversial. In this study, we conducted a prospective, randomized comparative trial to evaluate healing effects of vonoprazan and lansoprazole on endoscopic submucosal dissection (ESD)-induced ulcers. We enrolled 216 patients who underwent endoscopic submucosal dissection for early gastric neoplasms. They were randomly divided into vonoprazan (20 mg/day) and lansoprazole (30 mg/day) groups. The primary endpoint was the reduction rate of ulcer and complete healing (scar) ratio of ESD-induced ulcers at 4 and 8 weeks. Finally, 101 patients of the vonoprazan group and 95 patients of the lansoprazole group were included in the analysis. There were no significant differences in the reduction rate between the vonoprazan and lansoprazole groups at either timepoint (4 weeks, 94.0 vs 93.4%; 8 weeks, 99.8 vs 99.9%, respectively). The complete healing ratio at 4 and 8 weeks did not differ significantly between the vonoprazan and lansoprazole groups (4 weeks, 11.9 vs 12.6%; 8 weeks, 87.1 vs 86.3%, respectively). In the anti-H. pylori-antibody negative or positive patients, there were no significant differences in the reduction rate and complete healing ratio between the vonoprazan and lansoprazole groups. Regardless of treatment choice, the overall complete healing ratio at 8 weeks was significantly higher in the anti-H. pylori-antibody negative patients than the positive patients (p = 0.006). The healing effects of vonoprazan on ESD-induced ulcers were comparative to those of lansoprazole.

Effectiveness of fibrin sealant as a hemostatic technique in accelerating endoscopic submucosal dissection-induced ulcer healing and preventing stricture in the esophagus: A retrospective study

The aim of the present retrospective study was to evaluate the effectiveness of conservative electrocoagulation followed by porcine fibrin sealant (FS) as a protective hemostatic technique for wounded microvessels in promoting the healing of endoscopic submucosal dissection (ESD)-induced ulcer, and preventing esophageal strictures that follow ESD. A total of 203 patients with early esophageal cancer or precancerous lesions were retrospectively analyzed. The 1-month ulcer healing and stricture rates were compared between the two groups (combined hemostats and electrocautery groups). The 1-month complete healing rate was 77.0% in the combined hemostats group and 52.6% in the electrocautery group (P=0.003). The use of FS and a smaller resected range (<3/4 circumference) was associated with a better 1-month healing rate. For patients with a ≥3/4 circumference mucosal defect, the esophageal stricture rate was 31.6% (6/19) in the combined hemostats group and 25.0% (2/8) in the electrocautery group. There was no difference in the stricture rate (P=0.737) and dilation time (P=0.733) between the two groups. In conclusion, the application of conservative electrocoagulation followed by porcine FS as a wound-protection technique promoted ESD-induced ulcer healing in the esophagus. However, this combined hemostatic technique was not superior to the conventional hemostatic method in preventing post-ESD stricture in patients with large esophageal mucosal defects.