Endoscopy International Open, Table of Contents

CC BY-NC-ND 4.0 · Endosc Int Open 2020; 08(11): E1698-E1706
DOI: 10.1055/a-1261-3103

Original article

Stenting to prevent esophageal stricture after circumferential endoscopic submucosal dissection: an experimental study

Jan Martinek‡

¹Institute for Clinical and Experimental Medicine, Hepatogastroenterology, Prague, Czech Republic

²Czech Academy of Sciences, Institute of Animal Physiology and Genetics, PIGMOD, Libechov, Czech Republic

³University of Ostrava Faculty of Medicine, Department of Clinic Subjects, Ostrava, Czech Republic

⁴Charles University, First Faculty of Medicine, Institute of Physiology, Prague, Czech Republic

,

Radek Dolezel‡

²Czech Academy of Sciences, Institute of Animal Physiology and Genetics, PIGMOD, Libechov, Czech Republic

⁶Charles University, Department of Surgery, 2nd Faculty of Medicine Central Military Hospital, Prague, Czech Republic.

,

Bara Walterova

²Czech Academy of Sciences, Institute of Animal Physiology and Genetics, PIGMOD, Libechov, Czech Republic

,

Marek Kollar

²Czech Academy of Sciences, Institute of Animal Physiology and Genetics, PIGMOD, Libechov, Czech Republic

⁴Charles University, First Faculty of Medicine, Institute of Physiology, Prague, Czech Republic

⁵Institute for Clinical and Experimental Medicine, Clinical and Transplant Pathology Centre, Prague, Czech Republic

,

Stefan Juhas

²Czech Academy of Sciences, Institute of Animal Physiology and Genetics, PIGMOD, Libechov, Czech Republic

,

Jana Juhasova

²Czech Academy of Sciences, Institute of Animal Physiology and Genetics, PIGMOD, Libechov, Czech Republic

,

Zuzana Vackova

¹Institute for Clinical and Experimental Medicine, Hepatogastroenterology, Prague, Czech Republic

⁴Charles University, First Faculty of Medicine, Institute of Physiology, Prague, Czech Republic

,

Rastislav Hustak

¹Institute for Clinical and Experimental Medicine, Hepatogastroenterology, Prague, Czech Republic

,

Jakub Erben

⁷Technical University of Liberec, Faculty of Textile Engineering, Department of Nonwovens and Nanofibrous Materials, Liberec, Czech Republic

› Author Affiliations

Abstract

Background and study aims Circular ESD (CESD) is a treatment option for patients with extensive early esophageal cancer. Its major drawback is the development of a stricture. Stenting may represent an attractive prevention strategy. We designed an experimental study to assess the effect of stents covered with acellular biomatrix (AB) and a drug-eluting stent.

Materials and methods Thirty-five 35 pigs underwent CESD and were randomized into six groups: G1 (control), G2 (SEMS), G3 (SEMS + AB), G4 (SEMS + AB + steroid-eluting layer), G5 (biodegradable stent [BD]), G6 (BD + AB). SEMS were placed alongside the post-CESD defect, fixed and removed after 21 days. The main outcomes were stricture development, severity, and histopathology.

Results Pigs with BD stents (G5, 6) experienced severe inflammation and hypergranulation without biodegradation, therefore, these groups were closed prematurely. Significant strictures developed in 29 of 30 pigs (96.7 %). The most severe stricture developed in G2 and G4 (narrowest diameter (mm) 8.5 ± 3, 3 (G2) and 8.6 ± 2.1 (G4) vs. 17 ± 7.3 (G1) and 13.5 ± 8.3 (G3); P < 0.01. Signs of re-epithelization were present in 67 % and 71 % in G1 and G2 and in 100 % in G3 and G4. The most robust re-epithelization layer was present in G4. The inflammation was the most severe in G1 (mean score 2.3) and least severe in G4 (0.4).

Conclusions Stenting did not effectively prevent development of post-CESD esophageal stricture. SEMS with AB resulted in improved re-epithelization and decreased stricture severity. Steroid-eluting SEMS suppressed inflammation. BD stents seem inappropriate for this indication.

References
1 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal issection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829-854
2 Miwata T, Oka S, Tanaka S. et al. Risk factors for esophageal stenosis after entire circumferential endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma. Surg Endosc 2016; 30: 4049-4056
3 Martínek J, Juhas S, Dolezel R. et al. Prevention of esophageal strictures after circumferential endoscopic submucosal dissection. Minerva Chir 2018; 73: 394-409
4 Oliveira JF, Moura EG, Bernardo WM. et al. Prevention of esophageal stricture after endoscopic submucosal dissection: a systematic review and meta-analysis. Surg Endosc 2016; 30: 2779-2791
5 Wen J, Lu Z, Yang Y. et al. Preventing stricture formation by covered esophageal stent placement after endoscopic submucosal dissection for early esophageal cancer. Dig Dis Sci 2014; 59: 658-663
6 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
7 Zajicek R, Mandys V, Mestak O. et al. Human keratinocyte growth and differentiation on acellular porcine dermal matrix in relation to wound healing potential. Sci World J 2012; 2012: 727352
8 Matoušková E, Mestak O. The effect of different biologic and biosynthetic wound covers on keratinocyte growth, stratification and differentiation in vitro. J Tissue Eng 2014; 5: 2041731414554966
9 Zajicek R, Matouskova E, Broz L. et al. New biological temporary skin cover Xe-Derma (®) in the treatment of superficial scald burns in children. Burns 2011; 37: 333-337
10 Fischer A, Bausch D, Baier P. et al. Risk of biodegradable stent-induced hypergranulation causing re-stenosis of a gastric conduit after esophageal resection. Endoscopy 2012; 44: E125-126
11 Saito Y, Tanaka T, Andoh A. et al. Novel biodegradable stents for benign esophageal strictures following endoscopic submucosal dissection. Dig Dis Sci 2008; 53: 330-333
12 Shi Q, Ju H, Yao LQ. et al. Risk factors for postoperative stricture after endoscopic submucosal dissection for superficial esophageal carcinoma. Endoscopy 2014; 46: 640-644
13 Yamaguchi N, Isomoto H, Nakayama T. et al. Usefulness of oral prednisolone in the treatment of esophageal stricture after endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma. Gastrointest Endosc 2011; 73: 1115-1121
14 Shoji H, Yamaguchi N, Isomoto H. et al. Oral prednisolone and triamcinolone injection for gastric stricture after endoscopic submucosal dissection. Ann Transl Med 2014; 2: 22
15 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
16 Takahashi H, Arimura Y, Okahara S. et al. A randomized controlled trial of endoscopic steroid injection for prophylaxis of esophageal stenoses after extensive endoscopic submucosal dissection. BMC Gastroenterol 2015; 15: 1
17 Hashimoto S, Mizuno KI, Takahashi K. et al. Evaluating the effect of injecting triamcinolone acetonide in two sessions for preventing esophageal stricture after endoscopic submucosal dissection. Endosc Int Open 2019; 7: E764-E770
18 Martinek J. How to prevent post-ESD esophageal stricture. Endosc Int Open 2019; 7: E771-E773
19 Ye LP, Zheng HH, Mao XL. et al. Complete circular endoscopic resection using submucosal tunnel technique combined with esophageal stent placement for circumferential superficial esophageal lesions. Surg Endosc 2016; 30: 1078-1085
20 Han Y, Guo J, Sun S. et al. Acellular dermal matrix for esophageal stricture prevention after endoscopic submucosal dissection in a porcine model. Gastrointest Endosc 2017; 86: 1160-1167
21 Schomisch SJ, Yu L, Wu Y. et al. Commercially available biological mesh does not prevent stricture after esophageal mucosectomy. Endoscopy 2014; 46: 144-148
22 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
23 Li L, Linghu E, Chai N. et al. Efficacy of triamcinolone-soaked polyglycolic acid sheet plus fully covered metal stent for preventing stricture formation after large esophageal endoscopic submucosal dissection. Dis Esophagus 2019; 32