Endoscopy 2015; 47(04): 289-290
DOI: 10.1055/s-0034-1391733
Editorial
© Georg Thieme Verlag KG Stuttgart · New York

Prevention of stricture after large esophageal endoscopic submucosal dissections

Tsuneo Oyama
Department of Gastroenterology, Saku Central Hospital, Nagano, Japan
› Author Affiliations
Further Information

Publication History

Publication Date:
31 March 2015 (online)

Ten years have passed since the esophageal endoscopic submucosal dissection (ESD) technique was first developed. ESD is a useful treatment for superficial esophageal cancers, its advantages being high R0 resection rate, more precise histological examination, and low local recurrence rate [1]. However, in situations where semicircumferential or circumferential ESD is performed for esophageal lesions, severe strictures occur, which worsen the subsequent quality of life of the patients.

A number of different methods have been reported to prevent stricture formation after semicircumferential endoscopic mucosal resection (EMR) or ESD. These methods have been classified into four main groups.

The oldest and simplest method of preventing strictures is balloon dilation; however, thirty or more dilations are necessary after circumferential esophageal ESD [2] [3]. Therefore, balloon dilation has been deemed unacceptable as a standard treatment procedure following semicircumferential EMR or ESD.

The second method used is stent insertion [4] [5] [6]. Temporary insertion of a self-expandable esophageal stent is a possible treatment for esophageal strictures, but repeat stricture formation after stent removal remains a big problem. Some reports have shown the usefulness of biodegradable esophageal stents for the treatment of esophageal stricture; however, their use is associated with problems including migration and perforation, and such stents have not been able to prevent stricture formation after circumferential ESD.

The third method uses steroids via either injection or oral intake after esophageal ESD. The efficacy of endoscopic triamcinolone injection for the prevention of esophageal stricture after ESD has been reported by several authors [7] [8]. The major problem with the injection method is delayed perforation if the steroid is injected into the true mucosal layer. Therefore, triamcinolone must be injected into the submucosal layer. Effective administration of the steroid into the submucosal layer requires submucosal dissection at the middle level of the submucosal layer to create enough space for the steroid injection. Alternatively, oral intake of steroids is also a useful method to prevent stricture after semicircumferential esophageal ESD [9]. However, there are some disadvantages to using oral steroids including general adverse events, such as: vulnerability to infection, diabetes mellitus, and others. Therefore, oral prednisolone requires a prescription of antituberculosis drugs as well. According to the comprehensive registry of the Japan Esophageal Association, two patients have died of infectious disease after being treated with oral steroid therapy.

The final technique, which involves covering the ESD defect, is promising. As reported by Ohki et al. [10], this technique can prevent stricture formation by transplanting sheets of cells onto the defect. Endoscopic transplantation of the carrier-free cell sheets, which were composed of autologous oral mucosal epithelial cells, safely and effectively promoted re-epithelialization of the esophagus after ESD. Patients in this study did not experience any serious complications. Therefore, this procedure might be used to prevent stricture formation and improve the quality of life of patients following ESD.

Recently, a novel technique using a polyglycolic acid (PGA) sheet (Neoveil, Gunze Co, Kyoto, Japan) with fibrin glue (Bolheal, Chemo-Sero-Therapeutic Research Institute, Kumamoto, Japan; or Beriplast P combi-set, CSL Behring Pharma, Tokyo, Japan) has been reported [11] [12], and is being called the “mucosal defect covered with fibrin glue and PGA sheet” (MCFP) technique. The PGA sheet is an absorbable suture stiffener, which can prevent inflammation from causing fibrosis in the muscle layer. Using this technique, esophageal stricture 6 weeks after ESD occurred in 1 of 13 patients (7.7 %) [11]. The overall incidence of postoperative stricture was 37.5 % (3/8) and the number of endoscopic balloon dilation (EBD) sessions required was 0.8 ± 1.2 sessions [12].

This PGA sheet technique has some problems. The intricate technique, if small sheets are used, requires a long time to deliver the PGA sheet to the surface of the artificial ulcer because the scope must be repeatedly moved in and out [11]. The alternative delivery method is the clip-and-pull method [12]. However, the problem is that the PGA sheet is easily disturbed by subsequent oral intake of food, and the best delivery system needs to be established. In addition, the effectiveness of these techniques after circumferential ESD is not yet clear. Further study is needed to confirm that stricture formation can be prevented by these techniques.

 
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