A pilot experimental study of oesophageal stenosis after ESD


Authors: R. Doležel 1;  O. Ryska 2;  Š. Juhás 3;  J. Kalvach 1;  B. Walterová 4;  J. Martínek 5
Authors‘ workplace: Chirurgická klinika 2. LF UK a ÚVN Praha 1;  Chirurgické oddělení, Nemocnice Hořovice 2;  Ústav živočišné fyziologie a genetiky AV ČR, v. v. i., Liběchov 3;  Gymnázium Jana Palacha, Mělník 4;  Klinika hepatogastroenterologie, Transplantcentrum, IKEM, Praha 5
Published in: Gastroent Hepatol 2015; 69(5): 408-412
Category: Clinical and Experimental Gastroenterology: Original Article
doi: 10.14735/amgh2015408

Overview

Endoscopic submucosal dissection (ESD) is a challenging therapeutic method used to remove early neoplasms of the digestive tract. Complete circular ESD in the oesophagus is complicated by an extensive occurrence of postoperative strictures. Such strictures could be prevented using a metallic stent using biomaterial.

Method:
The pilot project was carried out over 12 months, using seven adult miniature pigs (bred in the laboratories of the Czech Academy of Science in Libechov). We used a single-channel endoscope. After tracing the edges and performing submucosal under-puncturing, we made a distal circular incision of the mucosa and then an identical oral circular incision 4–6 cm above it. We created three submucosal tunnels in the caudal direction using punctures and dissection. After completing the circular ESD, we pulled the mucosa outwards and the resection area was covered with oesophageal stents (six uncoated and one coated). Five primarily uncoated stents were coated with biodegradable material (Xe-Derma®). Three stents were attached to the wall of the oesophagus using endoscopic hemoclips. One week after the procedure, we conducted a control endoscopy followed by autopsy and histological analysis of the resection area.

Results:
All procedures were successfully completed without any major complications. Control endoscopy showed that the stents using biomaterial provide excellent protection to the resection area (i.e. no inflammation, no ulcer or tissue disintegration). Unfortunately, the biomaterial was not positioned optimally in any of the cases, even though the stent had always been deployed and anchored over the resection correctly. In two cases, the biomaterial slid from the stent and the bare-metal stent caused inflammation with fibrotic stenosis of the oesophagus. In animals where no biomaterial was used, the autopsy revealed 1× purulent mediastinitis and 1× para-oesophageal abscess. After one week the stent had migrated into the stomach in 71% (5/7) of the animals. Histological analysis of the resection area covered with biomaterial showed multi-layered re-epithelialization one week after the procedure. Deeper layers showed no signs of inflammation, without dysplasia, or granulomas from foreign cells.

Conclusion:
Biomaterial (Xe-Derma®) could be a suitable biological covering of the resection area after circular ESD with a positive effect on re-epithelialization and could hypothetically prevent stenosis. Migration of the stent covered with biomaterial has not yet been resolved.

Key words:
circular endoscopic submucosal dissection – complication – oesophageal strictures – submucosal tunnel

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE „uniform requirements“ for biomedical papers.

Submitted:
4. 9. 2015

Accepted:
22. 9. 2015


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Paediatric gastroenterology Gastroenterology and hepatology Surgery

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