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DOI: 10.1055/s-0033-1359125
An effective technique for delivery of polyglycolic acid sheet after endoscopic submucosal dissection of the esophagus: the clip and pull method
Publication History
Publication Date:
12 February 2014 (online)
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Endoscopic submucosal dissection (ESD) is currently accepted as an established method of treatment for esophageal superficial neoplasms, although it is associated with some complications [1]. Polyglycolic acid (PGA) sheet (Neoveil; Gunze Co., Kyoto, Japan) is an absorbable reinforcement material that has been used for reinforcing the surgical suture to prevent leakage [2]. It has also been reported to be effective in shielding the artificial ulcer after ESD thus preventing perforation or bleeding [3] [4]. However, shielding artificial ulcers is technically difficult especially in the esophagus due to its narrowness. This report describes a novel technique that enables rapid and easy shielding of the esophageal artificial ulcer.
A 69-year-old man underwent ESD for two large neighboring lesions in the middle part of the esophagus. Because the post-ESD artificial ulcer extended to over three-quarters of the circumference and was over 8 cm in longitudinal length ([Fig. 1]), we decided to shield it with a large PGA sheet using a novel delivery and deployment technique – the “clip and pull method” ([Fig. 2] and [Fig. 3]). After successful deployment of the PGA sheet over the artificial ulcer, the procedure was completed by spraying the area with fibrin glue (Beriplast P combi-set; CSL Behring Pharma, Tokyo, Japan), resulting in an artificial ulcer that was totally shielded in PGA sheet ([Fig. 4]).
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The patient recovered well after curative ESD without any complications, including bleeding or perforation, and was discharged on the 7th day. Although he underwent balloon dilation at follow-up endoscopy on the 22nd day after ESD because an endoscope did not pass through a mild stricture, he had not complained of any symptoms of dysphagia until the follow-up endoscopy. The artificial ulcer had been re-epithelialized with little reduction in the size of the ulcer bed ([Fig. 5]).
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This simple and effective method can be useful in shielding esophageal artificial ulcers in order to prevent complications including bleeding, perforation, and, potentially, postoperative stricture.
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References
- 1 Ono S, Fujishiro M, Koike K. Endoscopic submucosal dissection for superficial esophageal neoplasms. World J Gastrointest Endosc 2012; 4: 162-166
- 2 Nakamura T, Shimizu Y, Watanabe S et al. New bioabsorbable pledgets and non-woven fabrics made from polyglycolide (PGA) for pulmonary surgery: clinical experience. Thorac Cardiovasc Surg 1990; 38: 81-85
- 3 Takimoto K, Toyonaga T, Matsuyama K. Endoscopic tissue shielding to prevent delayed perforation associated with endoscopic submucosal dissection for duodenal neoplasms. Endoscopy 2012; 44 (Suppl. 02) E414-415
- 4 Tsuji Y, Ohata K, Gunji T et al. Endoscopic tissue shielding method with polyglycolic acid sheets and fibrin glue to cover wounds after colorectal endoscopic submucosal dissection (with video). Gastrointest Endosc 2013; [Epub ahead of print] DOI: 10.1016/j.gie.2013.08.041.