Editorial
289
Author
Tsuneo Oyama
Institution
Department of Gastroenterology, Saku Central Hospital, Nagano, Japan
Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1391733 Endoscopy 2015; 47: 289–290 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X
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 – 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
Corresponding author Tsuneo Oyama, MD PhD Saku Central Hospital Advanced Care Center – Endoscopy 3400-28 Nakagomi, Saku Nagano 385-0051 Japan Fax: +81-267-829638 [email protected]
Please see related article from Sakaguchi et al. p. 336.
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 carrierfree 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 post-
Oyama Tsuneo. Prevention of stricture after large esophageal ESDs … Endoscopy 2015; 47: 289–290
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Prevention of stricture after large esophageal endoscopic submucosal dissections
Editorial
operative 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.
5
6
7
8
9
Competing interests: None.
References 1 Oyama T, Tomori A, Hotta K et al. Endoscopic submucosal dissection of early esophageal cancer. Clin Gastroenterol Hepatol 2005; 3: S67 – S70 2 Sato H, Inoue H, Kobayashi Y et al. 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 – 257 3 Ezoe Y, Muto M, Horimatsu T et al. Efficacy of preventive endoscopic balloon dilation for esophageal stricture after endoscopic resection. J Clin Gastroenterol 2011; 45: 222 – 227 4 Pauli EM, Schomisch SJ, Furlan JP et al. Biodegradable esophageal stent placement does not prevent high-grade stricture formation after cir-
10
11
12
cumferential mucosal resection in a porcine model. Surg Endosc 2012; 26: 3500 – 3508 Saito YTanaka T, Andoh A et al. Novel biodegradable stents for benign esophageal strictures following endoscopic submucosal dissection. Dig Dis Sci 2008; 53: 330 – 333 Repici A, Vleggaar FP, Hassan C et al. Efficacy and safety of biodegradable stents for refractory benign esophageal strictures: the BEST (Biodegradable Esophageal Stent) study. Gastrointest Endosc 2010; 72: 927 – 934 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 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 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 Ohki T, Yamato M, Ota M et al. Prevention of esophageal stricture after endoscopic submucosal dissection using tissue-engineered cell sheets. Gastroenterology 2012; 143: 582 – 588 Iizuka T, Kikuchi D, Yamada A et al. Use of a polyglycolic acid sheet with fibrin glue to prevent esophageal stricture after endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma. Endoscopy 2015; 47: Sakaguchi Y, Tsuji Y, Ano S et al. Polyglycolic acid sheets with fibrin glue can prevent esophageal stricture after endoscopic submucosal dissection. Endoscopy 2015; 47: 336 – 340
Oyama Tsuneo. Prevention of stricture after large esophageal ESDs … Endoscopy 2015; 47: 289–290
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
290
Copyright of Endoscopy is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
289
Author
Tsuneo Oyama
Institution
Department of Gastroenterology, Saku Central Hospital, Nagano, Japan
Bibliography DOI http://dx.doi.org/ 10.1055/s-0034-1391733 Endoscopy 2015; 47: 289–290 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X
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 – 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
Corresponding author Tsuneo Oyama, MD PhD Saku Central Hospital Advanced Care Center – Endoscopy 3400-28 Nakagomi, Saku Nagano 385-0051 Japan Fax: +81-267-829638 [email protected]
Please see related article from Sakaguchi et al. p. 336.
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 carrierfree 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 post-
Oyama Tsuneo. Prevention of stricture after large esophageal ESDs … Endoscopy 2015; 47: 289–290
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
Prevention of stricture after large esophageal endoscopic submucosal dissections
Editorial
operative 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.
5
6
7
8
9
Competing interests: None.
References 1 Oyama T, Tomori A, Hotta K et al. Endoscopic submucosal dissection of early esophageal cancer. Clin Gastroenterol Hepatol 2005; 3: S67 – S70 2 Sato H, Inoue H, Kobayashi Y et al. 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 – 257 3 Ezoe Y, Muto M, Horimatsu T et al. Efficacy of preventive endoscopic balloon dilation for esophageal stricture after endoscopic resection. J Clin Gastroenterol 2011; 45: 222 – 227 4 Pauli EM, Schomisch SJ, Furlan JP et al. Biodegradable esophageal stent placement does not prevent high-grade stricture formation after cir-
10
11
12
cumferential mucosal resection in a porcine model. Surg Endosc 2012; 26: 3500 – 3508 Saito YTanaka T, Andoh A et al. Novel biodegradable stents for benign esophageal strictures following endoscopic submucosal dissection. Dig Dis Sci 2008; 53: 330 – 333 Repici A, Vleggaar FP, Hassan C et al. Efficacy and safety of biodegradable stents for refractory benign esophageal strictures: the BEST (Biodegradable Esophageal Stent) study. Gastrointest Endosc 2010; 72: 927 – 934 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 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 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 Ohki T, Yamato M, Ota M et al. Prevention of esophageal stricture after endoscopic submucosal dissection using tissue-engineered cell sheets. Gastroenterology 2012; 143: 582 – 588 Iizuka T, Kikuchi D, Yamada A et al. Use of a polyglycolic acid sheet with fibrin glue to prevent esophageal stricture after endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma. Endoscopy 2015; 47: Sakaguchi Y, Tsuji Y, Ano S et al. Polyglycolic acid sheets with fibrin glue can prevent esophageal stricture after endoscopic submucosal dissection. Endoscopy 2015; 47: 336 – 340
Oyama Tsuneo. Prevention of stricture after large esophageal ESDs … Endoscopy 2015; 47: 289–290
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
290
Copyright of Endoscopy is the property of Georg Thieme Verlag Stuttgart and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
