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Endoscopy 2016; 48(02): 117-122
DOI: 10.1055/s-0034-1393303
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Comparison of the histopathological effects of two electrosurgical currents in an in vivo porcine model of esophageal endoscopic mucosal resection

Farzan F. Bahin
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
2   Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
,
Nicholas G. Burgess
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
2   Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
,
Sharir Kabir
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
3   Department of Surgery, Westmead Hospital, Sydney, New South Wales, Australia
,
Hema Mahajan
4   Department of Anatomical Pathology, Westmead Hospital, Sydney, New South Wales, Australia
,
Duncan McLeod
4   Department of Anatomical Pathology, Westmead Hospital, Sydney, New South Wales, Australia
,
Vishnu Subramanian
4   Department of Anatomical Pathology, Westmead Hospital, Sydney, New South Wales, Australia
,
Maria Pellise
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
,
Rebecca Sonson
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
,
Michael J. Bourke
1   Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
2   Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
› Author Affiliations
Further Information

Publication History

submitted 29 March 2015

accepted after revision 23 July 2015

Publication Date:
04 November 2015 (online)

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Video Comment on Farzan F. Bahin et al.Endoscopy 2016; 48(02): v6-v6
DOI: 10.1055/s-0041-111112

Background and study aims: Stricture formation is the main limitation of endoscopic resection in the esophagus. The optimal electrosurgical current (ESC) for endoscopic resection in the esophagus and other gastrointestinal sites is unknown. There may be a relationship between the type of ESC used and the development of post-procedure esophageal stricture. Unlike the low power coagulating current (LPCC), the microprocessor-controlled current (MCC), which alternates between short pulse cutting and coagulation, avoids high peak voltages that are thought to result in deep thermal injury. The aim of this study was to determine the histopathological variables associated with these two commonly employed ESCs used for esophageal endoscopic resection.

Methods: Standardized endoscopic resection of normal mucosa by band mucosectomy was performed by a single endoscopist in 12 adult pigs. The procedures were randomized 1 : 1 to either LPCC (ERBE 100 C at 25 W) or MCC (ERBE Endocut Q, Effect 3). Necropsy and esophagectomy were performed at 72 hours after the procedure. Two histopathologists, who were blinded to the ESC allocation, independently assessed the presence and depth of ulceration, necrosis and inflammation.

Results: A total of 45 resections were analyzed. In the LPCC and MCC groups, ulceration extending into the muscularis propria was present in 9/24 (37.5 %) and 1/21 (4.8 %) resected specimens, respectively (P = 0.04). Necrosis extending into the muscularis propria was present in 13/24 (54.1 %) and 1/21 (4.8 %) resected specimens, respectively (P = 0.002). One case of microperforation with muscularis propria injury was noted in the LPCC group compared with none in the MCC group. The quantified mean depth of ulceration, necrosis, and acute inflammation was significantly greater in the LPCC group. 

Conclusions: In an in vivo porcine survival model of esophageal endoscopic mucosal resection, the use of MCC resulted in significantly less deep thermal ulceration, necrosis, and acute inflammation compared with LPCC. MCC should be used in preference over LPCC for esophageal endoscopic resection.

Appendix e1

 

  • References

  • 1 Das A, Singh V, Fleischer DE et al. A comparison of endoscopic treatment and surgery in early esophageal cancer: an analysis of surveillance epidemiology and end results data. Am J Gastroenterol 2008; 103: 1340-1345
    CrossrefPubMedGoogle Scholar
  • 2 Moss A, Bourke MJ, Hourigan LF et al. Endoscopic resection for Barrett’s high-grade dysplasia and early esophageal adenocarcinoma: an essential staging procedure with long-term therapeutic benefit. Am J Gastroenterol 2010; 105: 1276-1283
    CrossrefPubMedGoogle Scholar
  • 3 Pech O, May A, Manner H et al. Long-term efficacy and safety of endoscopic resection for patients with mucosal adenocarcinoma of the esophagus. Gastroenterology 2014; 146: 652-660
    CrossrefPubMedGoogle Scholar
  • 4 Chung A, Bourke MJ, Hourigan LF et al. Complete Barrett’s excision by stepwise endoscopic resection in short-segment disease: long term outcomes and predictors of stricture. Endoscopy 2011; 43: 1025-1032
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Fitzgerald RC, di Pietro M, Ragunath K et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus. Gut 2014; 63: 7-42
    CrossrefPubMedGoogle Scholar
  • 6 Konda VJ, Gonzalez Haba Ruiz M, Koons A et al. Complete endoscopic mucosal resection is effective and durable treatment for Barrett’s-associated neoplasia. Clin Gastroenterol Hepatol 2014; 12: 2002-2010
    CrossrefPubMedGoogle Scholar
  • 7 Ancona E, Rampado S, Cassaro M et al. Prediction of lymph node status in superficial esophageal carcinoma. Ann Surg Oncol 2008; 15: 3278-3288
    CrossrefPubMedGoogle Scholar
  • 8 Liu L, Hofstetter WL, Rashid A et al. Significance of the depth of tumor invasion and lymph node metastasis in superficially invasive (T1) esophageal adenocarcinoma. Am J Surg Pathol 2005; 29: 1079-1085
    PubMedGoogle Scholar
  • 9 Westerterp M, Koppert LB, Buskens CJ et al. Outcome of surgical treatment for early adenocarcinoma of the esophagus or gastro-esophageal junction. Virchows Arch 2005; 446: 497-504
    CrossrefPubMedGoogle Scholar
  • 10 Pech O, Behrens A, May A et al. Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett’s oesophagus. Gut 2008; 57: 1200-1206
    CrossrefPubMedGoogle Scholar
  • 11 Bahin FF, Jayanna M, Hourigan LF et al. Long-term outcomes of a primary complete endoscopic resection strategy for short-segment Barrett’s esophagus with high-grade dysplasia and/or early esophageal adenocarcinoma. In press 2015 Gastrointest Endosc DOI: 10.1016/j.gie.2015.04.044.
    PubMedGoogle Scholar
  • 12 Lewis JJ, Rubenstein JH, Singal AG et al. Factors associated with esophageal stricture formation after endoscopic mucosal resection for neoplastic Barrett’s esophagus. Gastrointest Endosc 2011; 74: 753-760
    CrossrefPubMedGoogle Scholar
  • 13 Chennat J, Konda VJ, Ross AS et al. Complete Barrett’s eradication endoscopic mucosal resection: an effective treatment modality for high-grade dysplasia and intramucosal carcinoma – an American single-center experience. Am J Gastroenterol 2009; 104: 2684-2692
    CrossrefPubMedGoogle Scholar
  • 14 Prasad GA, Wu TT, Wigle DA et al. Endoscopic and surgical treatment of mucosal (T1a) esophageal adenocarcinoma in Barrett’s esophagus. Gastroenterology 2009; 137: 815-823
    CrossrefPubMedGoogle Scholar
  • 15 van Vilsteren FG, Pouw RE, Seewald S et al. Stepwise radical endoscopic resection versus radiofrequency ablation for Barrett’s oesophagus with high-grade dysplasia or early cancer: a multicentre randomised trial. Gut 2011; 60: 765-773
    CrossrefPubMedGoogle Scholar
  • 16 Singh M, Gupta N, Gaddam S et al. Practice patterns among U. S. gastroenterologists regarding endoscopic management of Barrett’s esophagus. Gastrointest Endosc 2013; 78: 689-695
    CrossrefPubMedGoogle Scholar
  • 17 Morris ML, Tucker RD, Baron TH et al. Electrosurgery in gastrointestinal endoscopy: principles to practice. Am J Gastroenterol 2009; 104: 1563-1574
    CrossrefPubMedGoogle Scholar
  • 18 Rey JF, Beilenhoff U, Neumann CS et al. European Society of Gastrointestinal Endoscopy (ESGE) guideline: the use of electrosurgical units. Endoscopy 2010; 42: 764-772
    Article in Thieme ConnectPubMedGoogle Scholar
  • 19 Tokar JL, Barth BA, Banerjee S et al. Electrosurgical generators. Gastrointest Endosc 2013; 78: 197-208
    CrossrefPubMedGoogle Scholar
  • 20 Burgess NG, Williams SJ, Hourigan LF et al. A management algorithm based on outcomes of clinically significant delayed bleeding after wide-field endoscopic mucosal resection of large colonic lesions. Clin Gastroenterol Hepatol 2014; 12: 1525-1533
    CrossrefPubMedGoogle Scholar
  • 21 Van Gossum A, Cozzoli A, Adler M et al. Colonoscopic snare polypectomy: analysis of 1485 resections comparing two types of current. Gastrointest Endosc 1992; 38: 472-475
    CrossrefPubMedGoogle Scholar
  • 22 Fry LC, Lazenby AJ, Mikolaenko I et al. Diagnostic quality of: polyps resected by snare polypectomy: does the type of electrosurgical current used matter?. Am J Gastroenterol 2006; 101: 2123-2127
    CrossrefPubMedGoogle Scholar
  • 23 Johnson EE. A study of corrosive esophagitis. Laryngoscope 1963; 73: 1651-1696
    CrossrefPubMedGoogle Scholar
  • 24 Riddell R. Healing and repair. In: Snape WJ, Collins SM, eds. The effects of immune cells and inflammation on smooth muscle and enteric nerves. Boca Raton: CRC Press; 1990
    Google Scholar
  • 25 Van de Voorde W, Coermans G, Lerut T et al. Caustic oesophagitis seen through the microscope. Tijdsch Gastroenterol 1989; 145-150
    PubMedGoogle Scholar
  • 26 Mashimo H, Goyal R. Physiology of esophageal motility. GI Motility online 2006;
    PubMedGoogle Scholar
  • 27 Barret M, Batteux F, Beuvon F et al. N-acetylcysteine for the prevention of stricture after circumferential endoscopic submucosal dissection of the esophagus: a randomized trial in a porcine model. Fibrogenesis Tissue Repair 2012; 5: 8
    CrossrefPubMedGoogle Scholar
  • 28 Barret M, Pratico CA, Camus M et al. Amniotic membrane grafts for the prevention of esophageal stricture after circumferential endoscopic submucosal dissection. PloS One 2014; 9: e100236
    CrossrefPubMedGoogle Scholar
  • 29 Bhat YM, Kane SD, Shah JN et al. Single-session circumferential EMR and metal stent placement for the treatment of long-segment Barrett’s esophagus with high-grade intraepithelial neoplasia. Gastrointest Endosc 2014; 80: 331
    CrossrefPubMedGoogle Scholar
  • 30 Hanaoka N, Ishihara R, Takeuchi Y et al. Intralesional steroid injection to prevent stricture after endoscopic submucosal dissection for esophageal cancer: a controlled prospective study. Endoscopy 2012; 44: 1007-1011
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Hashimoto S, Kobayashi M, Takeuchi M et al. The efficacy of endoscopic triamcinolone injection for the prevention of esophageal stricture after endoscopic submucosal dissection. Gastrointest Endosc 2011; 74: 1389-1393
    CrossrefPubMedGoogle Scholar
  • 32 Hochberger J, Koehler P, Wedi E et al. Transplantation of mucosa from stomach to esophagus to prevent stricture after circumferential endoscopic submucosal dissection of early squamous cell. Gastroenterology 2014; 146: 906-909
    CrossrefPubMedGoogle Scholar
  • 33 Holt BA, Jayasekeran V, Williams SJ et al. Early metal stent insertion fails to prevent stricturing after single-stage complete Barrett’s excision for high-grade dysplasia and early cancer. Gastrointest Endosc 2015; 81: 857-864
    CrossrefPubMedGoogle Scholar
  • 34 Lee WJ, Jung HY, Kim doH et al. Intralesional steroid injection to prevent stricture after near-circumferential endoscopic submucosal dissection for superficial esophageal cancer. Clin Endosc 2013; 46: 643-646
    CrossrefPubMedGoogle Scholar
  • 35 Pauli EM, Schomisch SJ, Furlan JP et al. Biodegradable esophageal stent placement does not prevent high-grade stricture formation after circumferential mucosal resection in a porcine model. Surg Endosc 2012; 26: 3500-3508
    CrossrefPubMedGoogle Scholar
  • 36 Sakurai T, Miyazaki S, Miyata G et al. Autologous buccal keratinocyte implantation for the prevention of stenosis after EMR of the esophagus. Gastrointest Endosc 2007; 66: 167-173
    CrossrefPubMedGoogle Scholar
  • 37 May A, Gossner L, Behrens A et al. A prospective randomized trial of two different endoscopic resection techniques for early stage cancer of the esophagus. Gastrointest Endosc 2003; 58: 167-175
    CrossrefPubMedGoogle Scholar
  • 38 Pouw RE, van Vilsteren FG, Peters FP et al. Randomized trial on endoscopic resection-cap versus multiband mucosectomy for piecemeal endoscopic resection of early Barrett’s neoplasia. Gastrointest Endosc 2011; 74: 35-43
    CrossrefPubMedGoogle Scholar
  • 39 Grin A, Streutker CJ. Histopathology in Barrett esophagus and Barrett esophagus-related dysplasia. Clin Endosc 2014; 47: 31-39
    CrossrefPubMedGoogle Scholar
  • 40 Kumarasinghe MP, Brown I, Raftopoulos S et al. Standardised reporting protocol for endoscopic resection for Barrett oesophagus associated neoplasia: expert consensus recommendations. Pathology 2014; 46: 473-480
    CrossrefPubMedGoogle Scholar