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Kim Y, Na HK, Ahn JY, Lee JH, Jung KW, Kim DH, Choi KD, Song HJ, Lee GH, Jung HY. Association of local steroid injection as a risk factor for electrocoagulation syndrome after esophageal endoscopic submucosal dissection. Surg Endosc 2024; 38:3858-3865. [PMID: 38831214 DOI: 10.1007/s00464-024-10927-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 05/15/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Postendoscopic submucosal dissection electrocoagulation syndrome (PEECS) is commonly observed after performing endoscopic submucosal dissection (ESD) for esophageal neoplasia. However, data on the incidence and risk factors for PEECS in the esophagus are lacking due to an unclear definition of PEECS and varied clinical settings. Therefore, we aimed to determine the risk factors for PEECS in patients undergoing ESD for esophageal neoplasia. METHODS We retrospectively reviewed data of relevant clinical and endoscopy-specific parameters from 202 consecutive patients with esophageal neoplasias (139 carcinomas and 63 dysplasias) who underwent ESD under general anesthesia. Esophageal PEECS was defined by satisfying at least two of the following criteria: fever ≥ 37.8 °C, leukocytosis ≥ 10,800/mm3, and localized chest pain ≥ 5/10 points as assessed on a numeric rating scale within 24 h after ESD. Significant factors associated with PEECS were determined by regression analysis. RESULTS PEECS was recorded in 98 of 202 (48.5%) patients. Patients with PEECS exhibited a larger tumor size (25.0 vs. 17.0 mm, P = 0.002), longer procedure (40.0 vs. 29.5 min, P = 0.021) and hemostasis times (5.0 vs. 3.5 min, P = 0.004), required greater submucosal injection volume (60.0 mL vs. 50.0 mL, P = 0.030), and had a lower rate of local steroid injection (4.1% vs. 12.5%, P = 0.029) than those without PEECS. Multivariate regression analysis revealed tumor size ≥ 17 mm (P = 0.047), procedure time ≥ 33 min (P = 0.027), and hemostasis time ≥ 5 min (P = 0.007) as risk factors for PEECS. In addition, local steroid injection was a significant negatively associated factor (P = 0.001). CONCLUSIONS Patients with a large tumor, prolonged procedure and hemostasis times are at a high risk of PEECS occurrence. Further, local steroid injection is a negatively associated factor.
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Affiliation(s)
- Yuri Kim
- Division of Gastroenterology, Department of Internal Medicine, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu, Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea.
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Korea
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Pan Q, Tsuji Y, Sreedevi Madhavikutty A, Ohta S, Fujisawa A, Inagaki NF, Fujishiro M, Ito T. Prevention of esophageal stenosis via in situ cross-linkable alginate/gelatin powder in a new submucosal exfoliation model in rats. Biomater Sci 2023; 11:6781-6789. [PMID: 37614197 DOI: 10.1039/d3bm00887h] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
Endoscopic submucosal dissection (ESD) for the treatment of esophageal mucosal lesions often leads to postoperative stenosis, causing difficulty in swallowing, known as dysphagia. In this study, we developed an in situ cross-linkable powder composed of alginate, gelatin, transglutaminase (TG), and calcium chloride ions (Ca2+), which can be administered through a 1.5 m-long and 3.2 mm-diameter endoscopic instrument channel. The powdered mixture of alginate and gelatin quickly formed a hydrogel by absorbing body fluids and was cross-linked by TG and Ca2+, which adhered ex vivo to porcine submucosal layers for over 2 weeks. In addition, we developed a new submucosal exfoliation model in rats that induced severe stenosis, similar to the ESD-induced stenosis models in clinical practice. When administered to the new rat model, the powder system effectively reduced the severity of esophageal stenosis based on body weight change monitoring, anatomical findings, and histological analysis. The body weight of the rats was maintained at the initial weight on postoperative day 14 (POD14), and epithelialization on POD7 and 14 improved to almost 100%. Additionally, collagen accumulation and the number of α-SMA-positive cells decreased due to powder administration. Therefore, these findings indicate that the in situ cross-linkable powder can prevent esophageal stenosis after ESD.
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Affiliation(s)
- Qi Pan
- Center for Disease Biology and Integrative Medicine, School of Medicine, the University of Tokyo, Japan.
| | - Yosuke Tsuji
- Department of Gastroenterology, School of Medicine, the University of Tokyo, Japan
| | | | - Seiichi Ohta
- Center for Disease Biology and Integrative Medicine, School of Medicine, the University of Tokyo, Japan.
- Institute of Engineering Innovation, School of Engineering, the University of Tokyo, Japan
- Department of Bioengineering, School of Engineering, the University of Tokyo, Japan
| | - Ayano Fujisawa
- Department of Bioengineering, School of Engineering, the University of Tokyo, Japan
| | - Natsuko F Inagaki
- Center for Disease Biology and Integrative Medicine, School of Medicine, the University of Tokyo, Japan.
| | - Mitsuhiro Fujishiro
- Department of Gastroenterology, School of Medicine, the University of Tokyo, Japan
| | - Taichi Ito
- Center for Disease Biology and Integrative Medicine, School of Medicine, the University of Tokyo, Japan.
- Department of Chemical System Engineering, School of Engineering, the University of Tokyo, Japan
- Department of Bioengineering, School of Engineering, the University of Tokyo, Japan
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Geng ZH, Zhu Y, Li QL, Fu PY, Xiang AY, Pan HT, Xu MD, Chen SY, Zhong YS, Zhang YQ, Ma LL, Hu JW, Cai MY, Qin WZ, Chen WF, Zhou PH. Muscular injury as an independent risk factor for esophageal stenosis after endoscopic submucosal dissection of esophageal squamous cell cancer. Gastrointest Endosc 2023; 98:534-542.e7. [PMID: 37207844 DOI: 10.1016/j.gie.2023.05.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 05/01/2023] [Accepted: 05/04/2023] [Indexed: 05/21/2023]
Abstract
BACKGROUND AND AIMS Stenosis after esophageal endoscopic submucosal dissection (ESD) has a high incidence, and muscular injury is an important risk factor for esophageal stenosis. Hence, this study aimed to classify muscular injury degrees and investigate their association with postoperative stenosis. METHODS This retrospective study included 1033 patients with esophageal mucosal lesions treated with ESD between August 2015 and March 2021. Demographic and clinical parameters were analyzed, and stenosis risk factors were identified using multivariate logistic regression. A novel muscular injury classification system was proposed and used to investigate the association between different muscular injury degrees and postoperative stenosis. Finally, a scoring system was established to predict muscular injury. RESULTS Of 1033 patients, 118 (11.4%) had esophageal stenosis. The multivariate analysis demonstrated that the history of endoscopic esophageal treatment, circumferential range, and muscular injury were significant risk factors for esophageal stenosis. Patients with type II muscular injuries tended to develop complex stenosis (n = 13 [36.1%], P < .05), and type II muscular injuries were more likely to predispose patients to severe stenosis than type I (73.3% and 92.3%, respectively). The scoring system showed that patients with high scores (3-6) were more likely to have muscular injury. The score model presented good discriminatory power in the internal validation (area under the receiver-operating characteristic curve, .706; 95% confidence interval, .645-.767) and goodness-of-fit in the Hosmer-Lemeshow test (P = .865). CONCLUSIONS Muscular injury was an independent risk factor for esophageal stenosis. The scoring system demonstrated good performance in predicting muscular injury during ESD.
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Affiliation(s)
- Zi-Han Geng
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Yan Zhu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Pei-Yao Fu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - An-Yi Xiang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Hai-Ting Pan
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Mei-Dong Xu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Shi-Yao Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Yun-Shi Zhong
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Yi-Qun Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Li-Li Ma
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Jian-Wei Hu
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ming-Yan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Wen-Zheng Qin
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Wei-Feng Chen
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
| | - Ping-Hong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China; Shanghai Collaborative Innovation Center of Endoscopy, Shanghai, China
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Zhan SG, Wu BH, Li DF, Yao J, Xu ZL, Zhang DG, Shi RY, Tian YH, Wang LS. Oral higher dose prednisolone to prevent stenosis after endoscopic submucosal dissection for early esophageal cancer. World J Clin Cases 2022; 10:13264-13273. [PMID: 36683621 PMCID: PMC9850988 DOI: 10.12998/wjcc.v10.i36.13264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 10/22/2022] [Accepted: 12/05/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Esophageal stenosis is one of the main complications of endoscopic submucosal dissection (ESD) for the treatment of large-area superficial esophageal squamous cell carcinoma and precancerous lesions (≥ 3/4 of the lumen). Oral prednisone is useful to prevent esophageal stenosis, but the curative effect remains controversial.
AIM To share our experience of the precautions against esophageal stenosis after ESD to remove large superficial esophageal lesions.
METHODS Between June 2019 and March 2022, we enrolled patients with large superficial esophageal squamous cell carcinoma and high-grade intraepithelial neoplasia experienced who underwent ESD. Prednisone (50 mg/d) was administered orally on the second morning after ESD for 1 mo, and tapered gradually (5 mg/wk) for 13 wk.
RESULTS In total, 14 patients met the inclusion criteria. All patients received ESD without operation-related bleeding or perforation. There were 11 patients with ≥ 3/4 and < 7/8 of lumen mucosal defects and 1 patient with ≥ 7/8 of lumen mucosal defect and 2 patients with the entire circumferential mucosal defects due to ESD. The longitudinal extension of the esophageal mucosal defect was < 50 mm in 3 patients and ≥ 50 mm in 11 patients. The esophageal stenosis rate after ESD was 0% (0/14). One patient developed esophageal candida infection on the 30th d after ESD, and completely recovered after 7 d of administration of oral fluconazole 100 mg/d. No other adverse events of oral steroids were found.
CONCLUSION Oral prednisone (50 mg/d) and prolonged prednisone usage time may effectively prevent esophageal stricture after ESD without increasing the incidence of glucocorticoid-related adverse events. However, further investigation of larger samples is required to warrant feasibility and safety.
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Affiliation(s)
- Sheng-Gang Zhan
- Department of Gastroenterology, Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen 518020, Guangdong Province, China
| | - Ben-Hua Wu
- Department of Gastroenterology, Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen 518020, Guangdong Province, China
| | - De-Feng Li
- Department of Gastroenterology, Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen 518020, Guangdong Province, China
| | - Jun Yao
- Department of Gastroenterology, Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen 518020, Guangdong Province, China
| | - Zheng-Lei Xu
- Department of Gastroenterology, Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen 518020, Guangdong Province, China
| | - Ding-Guo Zhang
- Department of Gastroenterology, Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen 518020, Guangdong Province, China
| | - Rui-Yue Shi
- Department of Gastroenterology, Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen 518020, Guangdong Province, China
| | - Yan-Hui Tian
- Department of Gastroenterology, Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen 518020, Guangdong Province, China
| | - Li-Sheng Wang
- Department of Gastroenterology, Second Clinical Medical College of Jinan University, Shenzhen People’s Hospital, Shenzhen 518020, Guangdong Province, China
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5
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Arantes VN, Ramos JA, White JR, Parra-Blanco A. Clinical effectiveness of short course oral prednisone for stricture prevention after semi-circumferential esophageal endoscopic submucosal dissection. Endosc Int Open 2022; 10:E753-E761. [PMID: 35692934 PMCID: PMC9187403 DOI: 10.1055/a-1789-0266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 12/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background and study aims Esophageal strictures (ES) occur frequently after semi-circumferential endoscopic submucosal dissection (ESD) for the eradication of superficial esophageal neoplasms and negatively impact a patient's quality of life. Oral corticosteroids have been shown to be clinically effective, but the most appropriate drug, dose and duration is yet to be determined. The aim of the study was to investigate the clinical effectiveness and safety of 30 mg prednisone with a shortened tapering schedule on ES after semi-circumferential ESD. Patients and methods This was a retrospective observational study that analyzed consecutive patients with esophageal neoplasms who underwent semi-circumferential ESD with a resection defect greater than 75 % of the circumference that received a protocol of oral steroids for stricture prevention. On postoperative day 3, 30 mg prednisone was prescribed, tapering weekly to 20 mg/10 mg/5 mg over 4 weeks. Follow-up included clinic consultation and endoscopic review at weeks 2 and 4. Effectiveness outcomes included ES rates, safety, tolerability, resection, dilatation and recurrence rates. Results Ninety ESD procedures were carried out during the specified time period and 18 patients met the inclusion criteria for the final analysis. The mean age was 61.5 years, lesion size was 52.5 mm, and final histology was squamous cell carcinoma in all patients. Incidence of intra-procedure complications was: bleeding 5.5 % (1/18) and ES 5.5 % (1/18), requiring a median two endoscopic dilatations. En bloc, R0 and curative resection rates were 88.8 %, 72.2 %, and 55.5 %, respectively. Conclusions The short tapering schedule of 30 mg oral prednisone is clinically efficacious and safe for prevention of ES after semi-circumferential ESD in Latin American patients.
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Affiliation(s)
- Vitor N. Arantes
- Endoscopy Unit, Alfa Institute of Gastroenterology, School of Medicine, Federal University of Minas Gerais, Hospital Mater Dei Contorno, Belo Horizonte, Brazil
| | - Josué Aliaga Ramos
- Faculty of Medicine, Cayetano Heredia Peruvian University, Digestive Endoscopy Unit of San Pablo Clinic, Surco, Lima, Department of Gastroenterology, “Jose Agurto Tello” Hospital, Lima, Peru, Associate member of the Society of Gastroenterology of Peru
| | - Jonathan Richard White
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, The University of Nottingham, Nottingham, UK.
| | - Adolfo Parra-Blanco
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.,Nottingham Digestive Diseases Centre, The University of Nottingham, Nottingham, UK.
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Xu Y, Lin Z, Zhong S, Liang W. Muscular injury was identified the risk factor of post-operative stenosis after large area but non-circumferential esophageal endoscopic submucosal dissection. Scand J Gastroenterol 2022:1-8. [PMID: 35148239 DOI: 10.1080/00365521.2022.2034939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Revised: 01/20/2022] [Accepted: 01/22/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The incidence of post-operative stenosis after esophageal Endoscopic Submucosal Dissection (ESD) ranks high. This study aimed to investigate the association between the degree of muscular injury and the incidence of post-operative stenosis. RESEARCH DESIGN This was a retrospective study of 133 patients with superficial esophageal lesions treated by non-circumferential ESD enrolled between January 2016 and May 2021 at two endoscopy centers. Demographic and clinical parameters were analyzed. A novel muscular injury classification system was proposed. Stenosis risk factors were identified using multivariate logistic regression. The association between the different degrees of muscular injury and the incidence of post-operative stenosis was investigated further by propensity score matching (PSM). RESULTS There were 133 cases evaluated in this study, 33 of which developed stenosis. Multivariate analysis suggested lesions located in the upper 1/3 of the esophagus, resections >5/6 of the circumference, and muscular injury (Grade 3 or 4 according to our proposed classification) were risk factors for stenosis. Correlation analysis suggested a positive association between the degree of muscular injury and the incidence of post-operative stenosis (r = 0.408, p < .05). For PSM, 29 stenosis cases were matched and univariate analysis further corroborated that muscular injuries of grade 3 (OR = 6.429, 95%CI = 1.318-31.367, p = .021) or 4 (OR = 7, 95%CI = 1.068-45.901, p = .043) were risk factors for stenosis. CONCLUSION Grade 3-4 muscular injury was identified as a risk factor of post-operative stenosis.
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Affiliation(s)
- Yanqin Xu
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Zhengrong Lin
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Shishun Zhong
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Wei Liang
- Department of Digestive Endoscopy, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou, Fujian, China
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Pih GY, Kim DH, Gong EJ, Na HK, Jung KW, Lee JH, Ahn JY, Choi KD, Song HJ, Lee GH, Jung HY. Preventing esophageal strictures with steroids after endoscopic submucosal dissection in superficial esophageal neoplasm. J Dig Dis 2019; 20:609-616. [PMID: 31509651 DOI: 10.1111/1751-2980.12819] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/08/2019] [Accepted: 09/09/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study aimed to investigate the efficacy of prophylactic steroid administration in preventing post-endoscopic submucosal dissection (ESD) esophageal stricture and to determine risk factors for these strictures. METHODS Patients who underwent ESD for superficial esophageal neoplasms with a mucosal defect affecting >75% of the esophageal circumference between January 2011 and August 2016 were eligible. Patients were classified into three groups, including ESD-alone group (n = 22), oral steroid group (n = 25) and intralesional steroid injection group (n = 6). Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors for esophageal stricture. RESULTS The stricture rate was 50.0%, 20.0% and 33.3% in the ESD-alone group, oral steroid group and steroid injection group, respectively. Patients treated with steroids had a significantly lower stricture rate than the ESD-alone group (22.6% vs 50.0%, P = 0.046). Additionally, oral steroid group had a significantly lower stricture rate than the ESD-alone group (P = 0.037). Multivariate analysis revealed that the extent of the circumferential mucosal defect was a significant risk factor for post-ESD strictures (odds ratio [OR] 13.015, 95% confidence interval [CI] 2.257-76.077, P = 0.004). The administration of steroids (OR 0.108, 95% CI 0.020-0.578, P = 0.009), specifically oral steroids (OR 0.109, 95% CI 0.019-0.622, P = 0.013), was associated with prevention of post-ESD strictures. CONCLUSION Oral steroid prophylaxis appears to be a safe and effective treatment in preventing post-ESD stricture and improving patients' quality of life.
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Affiliation(s)
- Gyu Young Pih
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, South Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Yang J, Wang X, Li Y, Lu G, Lu X, Guo D, Wang W, Liu C, Xiao Y, Han N, He S. Efficacy and safety of steroid in the prevention of esophageal stricture after endoscopic submucosal dissection: A network meta-analysis. J Gastroenterol Hepatol 2019; 34:985-995. [PMID: 30566746 DOI: 10.1111/jgh.14580] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 12/05/2018] [Accepted: 12/10/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Even though endoscopic submucosal dissection is an important endoscopic resection technique for gastrointestinal neoplasms, there are chances that postoperative esophageal stricture might take place as a side effect. Steroid applications were reported to be effective for the prevention of stricture formation. Therefore, this study aims to evaluate the efficacy and safety of different steroid applications. METHODS Eligible studies published on PubMed, the Cochrane Library, Embase, Web of Science, and Chinese Biomedical Literature Database before August 2018 were reviewed. The preventions were divided as placebo/no treatment, long-term oral steroid (LOS), median-term oral steroid, short-term oral steroid, single-dose steroid injection, multiple-dose steroid injection, topical superficial steroid, steroid injection combined with oral steroid, and preemptive endoscopic balloon dilatation. The primary outcomes were postoperative esophageal stricture rate and endoscopic balloon dilatation sessions required. Complications were also analyzed. RESULTS A total of 19 studies were included. The network meta-results illustrated that compared with the placebo, all kinds of steroid interventions were associated with lower rates of postoperative esophageal stenosis and less number of endoscopic balloon dilatation sessions. Moreover, combined therapy was no better than single regimen therapy. No significant differences between various steroid applications in the incidence of complications were spotted during this study. Based on the results of the network and clustered ranking, LOS might be the superior prevention for postoperative stricture with satisfying efficacy. CONCLUSION The present study showed that LOS appears to be the optimal prevention method for postoperative stricture formation.
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Affiliation(s)
- Jiahui Yang
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xin Wang
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yarui Li
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Guifang Lu
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xinlan Lu
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Dan Guo
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Wancong Wang
- Department of Gastroenterology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Chuan Liu
- Department of Gastroenterology, The Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ye Xiao
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Nini Han
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Shuixiang He
- Department of Gastroenterology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
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9
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Ishihara R. Prevention of esophageal stricture after endoscopic resection. Dig Endosc 2019; 31:134-145. [PMID: 30427076 DOI: 10.1111/den.13296] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 11/08/2018] [Indexed: 01/10/2023]
Abstract
Stricture formation after esophageal endoscopic resection has a negative impact on patients' quality of life because it causes dysphagia and requires multiple endoscopic dilations. Various methods by which to prevent stricture have recently been developed and reported. Among these methods, local steroid injection is the most commonly used and is currently considered the standard method for noncircumferential resection. However, local steroid injection has a limited effect on circumferential resection. Thus, oral steroid administration is used for such cases because it may have a stronger effect than local injection. Steroid treatment, both by local injection and oral administration, is effective and low-cost; however, it may cause fragility of the esophageal wall, resulting in adverse events such as perforation during balloon dilatation. Many innovative approaches have been developed, such as tissue-shielding methods with polyglycolic acid, tissue engineering approaches with autologous oral mucosal epithelial cell sheet transplantation, and stent insertion. These methods may be promising, but they are limited by a scarcity of data. Further investigations are needed to confirm the efficacy of these methods.
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Affiliation(s)
- Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
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10
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Wang J, Zhu XN, Zhu LL, Chen W, Ma YH, Gan T, Yang JL. Efficacy and safety of endoscopic submucosal tunnel dissection for superficial esophageal squamous cell carcinoma and precancerous lesions. World J Gastroenterol 2018; 24:2878-2885. [PMID: 30018482 PMCID: PMC6048426 DOI: 10.3748/wjg.v24.i26.2878] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 05/02/2018] [Accepted: 06/09/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the clinical outcomes of patients who underwent endoscopic submucosal tunnel dissection (ESTD) for esophageal squamous cell carcinoma (ESCC) and precancerous lesions.
METHODS ESTD was performed in 289 patients. The clinical outcomes of the patients and pathological features of the lesions were retrospectively reviewed.
RESULTS A total of 311 lesions were included in the analysis. The en bloc rate, complete resection rate, and curative resection rate were 99.04%, 81.28%, and 78.46%, respectively. The ESTD procedure time was 102.4 ± 35.1 min, the mean hospitalization time was 10.3 ± 2.8 d, and the average expenditure was 3766.5 ± 846.5 dollars. The intraoperative bleeding rate was 6.43%, the postoperative bleeding rate was 1.61%, the perforation rate was 1.93%, and the postoperative infection rate was 9.65%. Esophageal stricture and positive margin were severe adverse events, with an incidence rate of 14.79% and 15.76%, respectively. No tumor recurrence occurred during the follow-up period.
CONCLUSION ESTD for ESCC and precancerous lesions is feasible and relatively safe, but for large mucosal lesions, the rate of esophageal stricture and positive margin is high.
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Affiliation(s)
- Jin Wang
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
- State Key Laboratory of Biotherapy and Cancer Center, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Xiao-Nan Zhu
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Lin-Lin Zhu
- Department of General Practice, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Wei Chen
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Yi-Han Ma
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Tao Gan
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jin-Lin Yang
- Department of Gastroenterology and Hepatology, West China Hospital of Sichuan University, Chengdu 610041, Sichuan Province, China
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11
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Takahashi K, Sato Y, Takeuchi M, Sato H, Nakajima N, Ikarashi S, Hayashi K, Mizuno KI, Honda Y, Hashimoto S, Yokoyama J, Terai S. Changes in esophageal motility after endoscopic submucosal dissection for superficial esophageal cancer: a high-resolution manometry study. Dis Esophagus 2017; 30:1-8. [PMID: 28881900 DOI: 10.1093/dote/dox057] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2017] [Indexed: 12/11/2022]
Abstract
The effect of endoscopic submucosal dissection (ESD) on esophageal motility remains unknown. Therefore, the aim of this study is to elucidate changes in esophageal motility after ESD along with the cause of dysphagia using high-resolution manometry (HRM). This is a before-and-after trial of the effect of ESD on the esophageal motility. Twenty patients who underwent ESD for superficial esophageal carcinoma were enrolled in this study. Patients filled out a questionnaire about dysphagia and underwent HRM before and after ESD. Results before and after ESD were compared. Data were obtained from 19 patients. The number of patients who complained of dysphagia before and after ESD was 1/19 (5.3%) and 6/19 (31.6%), respectively (P = 0.131). Scores from the five-point Likert scale before and after ESD were 0.1 ± 0.5 and 1.0 ± 1.6, respectively (P = 0.043). The distal contractile integral (DCI) before and after ESD and the number of failed, weak, or fragmented contractions were not significantly different. However, in five patients with circumferential ESD, DCI was remarkably decreased and the frequency of fail, weak, or fragmented contractions increased. Univariate regression analysis showed a relatively strong inverse correlation of ΔDCI with the circumferential mucosal defect ratio {P < 0.01, standardized regression coefficient (r) = -0.65}, the number of stricture preventions (P < 0.01, r = -0.601), and the number of stricture resolutions (P < 0.01, r = -0.77). This HRM study showed that impairment of esophageal motility could be caused by ESD. The impairment of esophageal motility was conspicuous, especially in patients with circumferential ESD and subsequent procedures such as endoscopic triamcinolone injection and endoscopic balloon dilatation. Impaired esophageal motility after ESD might explain dysphagia.
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Affiliation(s)
- K Takahashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University
| | - Y Sato
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University
| | - M Takeuchi
- Division of Gastroenterology and Hepatology, Nagaoka Red Cross Hospital
| | - H Sato
- Division of Gastroenterology and Hepatology, Saiseikai Niigata Daini Hospital, Niigata, Japan
| | - N Nakajima
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University
| | - S Ikarashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University
| | - K Hayashi
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University
| | - K-I Mizuno
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University
| | - Y Honda
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University
| | - S Hashimoto
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University
| | - J Yokoyama
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University
| | - S Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University
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12
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Tsujii Y, Hayashi Y, Kawai N, Yamada T, Yamamoto K, Hayashi S, Yoshii S, Nagai K, Inoue T, Nishida T, Iijima H, Mita E, Inoue A, Takehara T. Risk of perforation in balloon dilation associated with steroid injection for preventing esophageal stricture after endoscopic submucosal dissection. Endosc Int Open 2017; 5:E573-E579. [PMID: 28670613 PMCID: PMC5482748 DOI: 10.1055/s-0043-110077] [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: 12/16/2016] [Accepted: 03/15/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic local steroid injection (LSI) has been used to prevent esophageal strictures after endoscopic submucosal dissection (ESD) for superficial esophageal neoplasms (SENs). This study aimed to evaluate the safety and efficacy of LSI therapy. PATIENTS AND METHODS From May 2007 to September 2014, at four institutions, 40 consecutive patients with SENs were treated with ESD that left a mucosal defect of more than three-quarters of the esophageal circumference. Two patients who underwent esophagectomy after ESD were excluded, and 38 patients were analyzed. The incidence of post-ESD strictures and adverse events associated with LSI were retrospectively investigated. RESULTS Prophylactic LSI was administered in 28 patients (LSI group), and not administered in 10 patients (Non-prevention group). Post-ESD stricture rates were significantly lower in the LSI group (43 %) than in the Non-prevention group (90 %) ( P = 0.012). Endoscopic balloon dilation (EBD) was conducted in 11 patients (39 %) in the LSI group and in 7 (70 %) in the Non-prevention group. In the LSI group, perforation caused by EBD occurred in five patients, while in the Non-prevention group, it occurred in only one patient who had received subsequent LSI before the perforation. Four patients with perforation successfully recovered after conservative therapy, but the other two patients required surgical treatment. A review of follow-up examinations with endoscopic ultrasonography and narrow-band imaging showed impaired ulcer-healing process after LSI. CONCLUSION LSI is useful for preventing post-ESD strictures, but it appears to increase the risk of perforation in cases of EBD.
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Affiliation(s)
- Yoshiki Tsujii
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yoshito Hayashi
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Naoki Kawai
- Department of Gastroenterology, Osaka General Medical Center, Osaka, Japan
| | - Takuya Yamada
- Department of Gastroenterology, Osaka National Hospital, National Hospital Organization, Osaka, Japan
| | - Katsumi Yamamoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan,Department of Gastroenterology, Osaka Hospital, Japan Community Health Care Organization, Osaka, Japan
| | - Shiro Hayashi
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Shunsuke Yoshii
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Kengo Nagai
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Takuya Inoue
- Department of Gastroenterology, Osaka General Medical Center, Osaka, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Hideki Iijima
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Eiji Mita
- Department of Gastroenterology, Osaka National Hospital, National Hospital Organization, Osaka, Japan
| | - Atsuo Inoue
- Department of Gastroenterology, Osaka General Medical Center, Osaka, Japan
| | - Tetsuo Takehara
- Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan,Corresponding author Tetsuo Takehara, MD PhD Department of Gastroenterology and HepatologyOsaka University Graduate School of Medicine2-2 YamadaokaSuitaOsaka 565-0871Japan+81-6-6879-3629
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13
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Kadota T, Yano T, Kato T, Imajoh M, Noguchi M, Morimoto H, Osera S, Yoda Y, Oono Y, Ikematsu H, Ohtsu A, Kaneko K. Prophylactic steroid administration for strictures after endoscopic resection of large superficial esophageal squamous cell carcinoma. Endosc Int Open 2016; 4:E1267-E1274. [PMID: 28028531 PMCID: PMC5179327 DOI: 10.1055/s-0042-118291] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Accepted: 09/09/2016] [Indexed: 02/08/2023] Open
Abstract
Background and study aims: One of the major complications after endoscopic resection (ER) for large superficial esophageal squamous cell carcinoma (ESCC) is benign esophageal stricture, which can reduce quality of life even if ESCC achieves a cure without organ resection. Recently, steroid administration has been reported as a prophylactic treatment to prevent esophageal strictures. This retrospective study evaluated the stricture rate according to the different width of mucosal defects due to ER and compared it to that seen with prophylactic steroid administration. Patients and methods: Between June 2007 and December 2013, we enrolled patients with ESCC who had 3/4 or larger circumferential mucosal defects due to ER. In December 2009, steroid injections (triamcinolone acetonide 50 mg) into the ulcer bed due to ER were introduced. Beginning in November 2012, we commenced oral steroid administration (prednisolone 30 mg/day, tapered gradually for 8 weeks) in addition to steroid injection. Patients were classified into 3 groups according to the width of mucosal defect after ER (Group A, ≥ 3/4 and < 7/8; Group B, ≥ 7/8 and less than the entire circumference; and Group C, the entire circumference). We retrospectively evaluated the stricture rate by comparing no treatment, steroid injection, or steroid injection followed by oral steroid according to the width of mucosal defect. Results: A total of 115 patients met the selection criteria. In Group B, no treatment had a significantly higher stricture rate (100 %, vs. steroid injection: 56 % P = 0.015; vs steroid injection followed by oral steroid: 20 % P < 0.001). Conversely, in Group C, the stricture rate was high, regardless of treatment (no treatment: 100 %; steroid injection: 100 %; steroid injection followed by oral steroid: 71 %). Conclusions: Although prophylactic steroid administration is effective to prevent strictures for 7/8 circumference or larger mucosal defects, it is ineffective for whole-circumference defects. Further investigation is required.
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Affiliation(s)
- Tomohiro Kadota
- Department of Gastroenterology, Endoscopy
Division, National Cancer Center Hospital East, Kashiwa, Chiba,
Japan,Course of Advanced Clinical Research of
Cancer, Juntendo University Graduate School of Medicine, Tokyo,
Japan
| | - Tomonori Yano
- Department of Gastroenterology, Endoscopy
Division, National Cancer Center Hospital East, Kashiwa, Chiba,
Japan,Corresponding author Tomonori
Yano Department of
GastroenterologyEndoscopy
DivisionNational Cancer Center Hospital
East6-5-1,
KashiwanohaKashiwa, Chiba
277-8577Japan+81-4-7133-111104-7134-6865
| | - Tomoji Kato
- Department of Gastroenterology, Endoscopy
Division, National Cancer Center Hospital East, Kashiwa, Chiba,
Japan
| | - Maomi Imajoh
- Department of Gastroenterology, Endoscopy
Division, National Cancer Center Hospital East, Kashiwa, Chiba,
Japan
| | - Masaaki Noguchi
- Department of Gastroenterology, Endoscopy
Division, National Cancer Center Hospital East, Kashiwa, Chiba,
Japan
| | - Hiroyuki Morimoto
- Department of Gastroenterology, Endoscopy
Division, National Cancer Center Hospital East, Kashiwa, Chiba,
Japan
| | - Shozo Osera
- Department of Gastroenterology, Endoscopy
Division, National Cancer Center Hospital East, Kashiwa, Chiba,
Japan
| | - Yusuke Yoda
- Department of Gastroenterology, Endoscopy
Division, National Cancer Center Hospital East, Kashiwa, Chiba,
Japan
| | - Yasuhiro Oono
- Department of Gastroenterology, Endoscopy
Division, National Cancer Center Hospital East, Kashiwa, Chiba,
Japan
| | - Hiroaki Ikematsu
- Department of Gastroenterology, Endoscopy
Division, National Cancer Center Hospital East, Kashiwa, Chiba,
Japan
| | - Atsushi Ohtsu
- Course of Advanced Clinical Research of
Cancer, Juntendo University Graduate School of Medicine, Tokyo,
Japan,Exploratory Oncology Research & Clinical
Trial Center, National Cancer Center, Kashiwa, Chiba, Japan
| | - Kazuhiro Kaneko
- Department of Gastroenterology, Endoscopy
Division, National Cancer Center Hospital East, Kashiwa, Chiba,
Japan
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14
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Miwata T, Oka S, Tanaka S, Kagemoto K, Sanomura Y, Urabe Y, Hiyama T, Chayama K. Risk factors for esophageal stenosis after entire circumferential endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma. Surg Endosc 2015; 30:4049-56. [PMID: 26703127 DOI: 10.1007/s00464-015-4719-3] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 12/07/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is used to perform en block resection for esophageal squamous cell carcinoma, but it is strongly associated with postoperative stenosis, especially during entire circumferential resection. This study aimed to clarify the risk factors for refractory postoperative stenosis after entire circumferential esophageal ESD. METHODS Nineteen patients who underwent entire circumferential esophageal ESD from February 2006 to December 2013 at Hiroshima University Hospital were divided into two groups: refractory postoperative stenosis [≥6 endoscopic balloon dilation (EBD) procedures, 12 lesions in 12 patients] and non-refractory postoperative stenosis (≤5 EBD procedures, 7 lesions in 7 patients). We retrospectively examined the patient factors (age, sex, alcohol consumption, smoking index, and chemoradiation therapy history), tumor factors (location, macroscopic type, fibrosis, and depth), and treatment factors (mean procedure time, entire circumferential resection diameter, muscle layer damage, and steroid administration method) between the two groups. RESULTS Muscle layer damage (p = 0.019) and ≥5 cm of longitudinal mucosal defect length after entire circumferential esophageal ESD (p = 0.010) were significant factors associated with the refractory group. Regarding the patient and tumor factors, there were no significant differences between the two groups. CONCLUSION Our data suggest that refractory post-ESD stenosis occurs after entire circumferential esophageal ESD with muscle layer damage and ≥5 cm of longitudinal mucosal defect length.
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Affiliation(s)
- Tomohiro Miwata
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Shiro Oka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan. .,Department of Gastroenterology and Metabolism, Graduate Departments of Endoscopy, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Kenichi Kagemoto
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Yoji Sanomura
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Yuji Urabe
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
| | - Toru Hiyama
- Health Service Center, Hiroshima University, Higashihiroshima, Japan
| | - Kazuaki Chayama
- Department of Gastroenterology and Metabolism, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
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15
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Evaluation of esophageal motility after endoscopic submucosal dissection for superficial esophageal cancer. Eur J Gastroenterol Hepatol 2015. [PMID: 26225867 DOI: 10.1097/meg.0000000000000431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Endoscopic submucosal dissection (ESD) is a standard treatment for superficial esophageal cancer. Some patients complain of dysphagia after ESD even without any postoperative strictures. Although ineffective esophageal motility might be associated with dysphagia after ESD, its effect on esophageal motility after ESD remains unknown. Therefore, we aimed to elucidate esophageal motility after ESD and the cause of dysphagia using high-resolution manometry (HRM). PATIENTS AND METHODS Seventy-six patients (men/women, 64/12; mean age, 71.2 years) who had undergone ESD for superficial esophageal cancer were enrolled. The results of ESD were retrospectively investigated using endoscopic images from the ESD and patient questionnaire for dysphagia. Each patient underwent HRM, and the results were evaluated using metrics and contraction patterns, according to the Chicago classification. RESULTS Data were obtained from 71 patients. The circumferential mucosal defect ratio (β=0.284, P=0.017), number of ESD (β=0.346, P=0.003), and number of endoscopic balloon dilatations (EBDs) (β=0.416, P<0.001) were correlated with the number of weak contraction with large breaks on HRM. The circumferential mucosal defect (odds ratio=1.074, P<0.001) and number of EBDs (odds ratio=1.200, P=0.035) were also significant predictors for dysphagia after ESD. CONCLUSION Circumferential mucosal defect ratio, EBD, and repeated ESD were predictors for impaired esophageal motility after ESD. Because circumferential mucosal defect ratios and EBD were also correlated with dysphagia after ESD, impaired esophageal motility could explain dysphagia after ESD.
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16
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Barret M, Beye B, Leblanc S, Beuvon F, Chaussade S, Batteux F, Prat F. Systematic review: the prevention of oesophageal stricture after endoscopic resection. Aliment Pharmacol Ther 2015; 42:20-39. [PMID: 25982288 DOI: 10.1111/apt.13254] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Revised: 02/28/2015] [Accepted: 04/30/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Extensive endoscopic resections for the treatment of early oesophageal neoplasia can result in fibro-inflammatory strictures that require repeated interventions, which significantly alter the patients' quality of life. AIMS To review current evidence about the prevention of oesophageal strictures following endoscopic resections. METHODS Systematic search of PubMed and Embase from inception to March 2015 using appropriate keywords. All original publications in English were included, and articles on the treatment of oesophageal stricture were excluded. RESULTS Of the 461 hits, 62 studies were included in the analysis. Among the wound-protective strategies, polyglycolic acid sheets showed the most convincing evidence with a 37.5% stricture rate and excellent safety. Regenerative medicine, using cell sheets of autologous keratinocytes, resulted in a 25% stricture rate, although with cost and availability concerns. Among anti-proliferative treatment modalities, steroid treatment, either endoscopically injected triamcinolone in the resection wound or orally administered prednisolone, proved effective with an overall stricture rate of 13.5%, with safety concerns regarding late oesophageal perforations and infectious morbidity. Among mechanical treatment options, poorly effective and high-risk preventive balloon dilation tend to be replaced by prophylactic covered stent, with 18-28% stricture rates. CONCLUSIONS Although oral or locally injected steroids are promising options, no currently available technique is sufficiently efficient and devoid of significant safety concerns to recommend its routine use for the prevention of strictures after extensive endoscopic resection. Improving our knowledge in the mechanisms of oesophageal wound healing will guide the development of novel methods for stricture prevention.
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Affiliation(s)
- M Barret
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,UI 1016, Faculté Paris Descartes, Paris, France
| | - B Beye
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,UI 1016, Faculté Paris Descartes, Paris, France
| | - S Leblanc
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - F Beuvon
- Department of Pathology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - S Chaussade
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - F Batteux
- UI 1016, Faculté Paris Descartes, Paris, France.,Department of Immunology, Cochin Hospital, Paris, France
| | - F Prat
- Department of Gastroenterology, Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France.,UI 1016, Faculté Paris Descartes, Paris, France
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17
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Locoregional steroid injection prevents stricture formation after endoscopic submucosal dissection for esophageal cancer: a propensity score matching analysis. Surg Endosc 2015; 30:1441-9. [PMID: 26123341 DOI: 10.1007/s00464-015-4348-x] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 06/15/2015] [Indexed: 12/17/2022]
Abstract
BACKGROUND Although endoscopic submucosal dissection (ESD) has become accepted for the treatment of superficial esophageal cancer, the incidence of stricture formation caused by ESD for widespread lesions is high and leads to a low quality of life. A few studies reported that locoregional steroid injections are useful for the prevention of such stricture formation compared with historical controls. We evaluated the efficacy of prophylactic locoregional steroid injections for stricture formation caused by ESD using quasi-randomized analysis. METHODS This matched case-control study included 461 superficial esophageal cancers from 305 patients who underwent ESD between 2006 and 2013. We used two methods of locoregional steroid injection to prevent stricture formation after ESD. A propensity score matching analysis was performed to reduce the effects of a selection bias for steroid injections and other potential confounding factors. In addition, generalized estimating equations were used to analyze repeated measures data. We compared the incidence of stricture formation with or without steroid injections. RESULTS Forty-two lesions were treated with locoregional steroid injection (dexamethasone/triamcinolone, 23/19) after ESD and esophageal stricture formation occurred in 36 lesions. Fifty-six lesions treated with or without steroid injections were matched after propensity score matching. Locoregional steroid injection reduced the incidence of stricture formation to 10.7% (3/28) of patients compared with 35.7% (10/28) in the control group (odds ratio 4.63, 95% confidence interval 1.11-19.25, p = 0.035). CONCLUSIONS Locoregional steroid injections could be efficient for the prevention of stricture formation after ESD for superficial esophageal cancer.
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18
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Uno K, Iijima K, Koike T, Shimosegawa T. Useful strategies to prevent severe stricture after endoscopic submucosal dissection for superficial esophageal neoplasm. World J Gastroenterol 2015; 21:7120-7133. [PMID: 26109798 PMCID: PMC4476873 DOI: 10.3748/wjg.v21.i23.7120] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 03/24/2015] [Accepted: 04/28/2015] [Indexed: 02/06/2023] Open
Abstract
The minimal invasiveness of endoscopic submucosal dissection (ESD) prompted us to apply this technique to large-size early esophageal squamous cell carcinoma and Barrett’s adenocarcinoma, despite the limitations in the study population and surveillance duration. A post-ESD ulceration of greater than three-fourths of esophageal circumference was advocated as an important risk factor for refractory strictures that require several sessions of dilation therapy. Most of the preoperative conditions are asymptomatic, but dilatation treatment for dysphagia associated with the stricture has potential risks of severe complications and a worsening of quality of life. Possible mechanisms of dysphasia were demonstrated based on dysmotility and pathological abnormalities at the site: (1) delayed mucosal healing; (2) severe inflammation and disorganized fibrosis with abundant extracellular matrices in the submucosa; and (3) atrophy in the muscularis proper. However, reports on the administration of anti-scarring agents, preventive dilation therapies, and regenerative medicine demonstrated limited success in stricture prevention, and there were discrepancies in the study designs and protocols of these reports. The development and consequent long-term assessments of new prophylactic technologies on the promotion of wound healing and control of the inflammatory/tumor microenvironment will require collaboration among various research fields because of the limited accuracy of preoperative staging and high-risk of local recurrence.
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19
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Sato H, Inoue H, Kobayashi Y, Maselli R, Santi EGR, Hayee B, Igarashi K, Yoshida A, Ikeda H, Onimaru M, Aoyagi Y, Kudo SE. Control of severe strictures after circumferential endoscopic submucosal dissection for esophageal carcinoma: oral steroid therapy with balloon dilation or balloon dilation alone. Gastrointest Endosc 2013; 78:250-7. [PMID: 23453294 DOI: 10.1016/j.gie.2013.01.008] [Citation(s) in RCA: 107] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 01/01/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent technological advances have allowed superficially spreading intramucosal carcinomas of the esophagus to be successfully resected by circumferential endoscopic submucosal dissection (cESD). After this procedure, esophageal strictures develop in most patients and are mainly treated by endoscopic balloon dilation (EBD). OBJECTIVE To compare oral steroids plus EBD with EBD alone for the management of benign esophageal strictures after cESD. DESIGN Retrospective cohort study. SETTING Tertiary-care referral center. PATIENTS We studied 23 consecutive patients who underwent complete cESD for superficial esophageal carcinoma (22 squamous cell carcinomas and 1 adenocarcinoma associated with Barrett's esophagus). INTERVENTION After cESD, patients were managed with EBD alone (EBD, n = 13) or with EBD and oral prednisolone (steroid + EBD, n = 10), 30 mg daily, started 2 days after cESD and gradually tapered and discontinued after 8 weeks. MAIN OUTCOME MEASUREMENTS Total number of EBD sessions and total EBD period (months). RESULTS Steroid + EBD patients required fewer sessions (13.8 ± 6.9 vs 33.5 ± 22.9; P < .001) and a shorter management period (4.8 ± 2.3 vs 14.2 ± 17.5 months, P = .005) compared with the EBD group. An additional 3 patients received oral steroids a mean interval of 158 days after cESD. These patients required more EBD sessions (46.3 ± 30.0; P = .002), and the EBD period was significantly longer (17.5 ± 13.0 months; P = .005) than in the early steroid + EBD group. LIMITATIONS Nonrandomized study; retrospective analysis. CONCLUSION After cESD, oral steroid therapy dramatically reduced the need for EBD. We conclude that oral steroid therapy after EBD is an effective strategy for the management of esophageal strictures after complete cESD.
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Affiliation(s)
- Hiroki Sato
- Digestive Disease Center, Showa University, Northern Yokohama Hospital, Yokohama, Japan
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