Efficacy of preventive endoscopic balloon dilation for esophageal stricture after endoscopic resection

Efficacy of short period, low dose oral prednisolone for the prevention of stricture after circumferential endoscopic submucosal dissection (ESD) for esophageal cancer

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) was developed in Japan and has been performed on many patients with early stage esophageal cancer; however quality of life in patients with postoperative stricture is drastically decreased and repeat, periodic endoscopic balloon dilatation (EBD) is usually required over long periods. In this study, we evaluate the efficacy of short period, low dose oral prednisolone in controlling post-procedural esophageal stricture.

PATIENTS AND METHODS

In total, 33 patients who underwent semicircular or complete circular ESD for esophageal superficial squamous cell carcinoma were included in this study. They were divided into two groups: those who underwent large-circumference ESD with no preventative treatment for stricture (ESD alone group) and those who received systemic steroid treatment for stricture (oral prednisolone group). We compared the two groups in terms of stricture rate and total number of EBD sessions. The ESD alone group underwent no preventative treatment. The oral prednisolone group started with 30 mg/day prednisolone on the second day post-ESD, and continued with a gradually tapering prednisolone dose, finally discontinuing systemic steroid administration 3 weeks later.

RESULTS

The stricture rate after ESD was significantly lower in the oral prednisolone group (3 of 17 patients; 17.6 %) than in the ESD alone group (11 of 16 patients; 68.7 %) (P < 0.01). The number of EBD sessions was significantly lower in the oral prednisolone group than in the ESD alone group (median 4.6, range 2 - 10 vs. median 8.1, range 1 - 18; P < 0.01).

CONCLUSION

Short period, low dose oral prednisolone showed promising results for the prevention of stricture after ESD for early stage esophageal cancers.

Disseminated nocardiosis during systemic steroid therapy for the prevention of esophageal stricture after endoscopic submucosal dissection

An 85-year-old man underwent endoscopic submucosal dissection for a large superficial esophageal epithelial neoplasm, which required removal of 95% of the circumference of the esophageal mucosa. Steroids were given orally to prevent esophageal stricture starting on day 3 postoperatively. In the 6th week of steroid treatment, he developed high fever without other symptoms. Chest computed tomography revealed a nodular lesion in the lung. Sputum sample showed Gram-positive, branching, filamentous bacteria, and a diagnosis of nocardiosis was suspected. Brain magnetic resonance imaging revealed multiple focal lesions which indicated dissemination of nocardiosis. Trimethoprim-sulfamethoxazole was immediately started, which led to the disappearance of pulmonary and cerebral nocardiosis with alleviation of fever. Recently, oral steroid treatment has been widely used for the prevention of esophageal stricture. However, the present case indicates the risk of life-threatening infection and the importance of close monitoring of this treatment.

A randomized controlled trial of endoscopic steroid injection for prophylaxis of esophageal stenoses after extensive endoscopic submucosal dissection

BACKGROUND

Esophageal stenosis following endoscopic submucosal dissection (ESD) is a serious adverse event that makes subsequent management more difficult.

METHODS

This parallel, randomized, controlled, open-label study was designed to examine whether local steroid injection is an effective prophylactic treatment for esophageal stenoses following extensive ESD. This single center trial was conducted at the Keiyukai Hospital, a tertiary care center for gastrointestinal disease in Japan [University Hospital Medical Network Clinical Trial Registry (UMIN-CTR) on 15 September 2011 (UMIN000006327)]. Thirty-two patients with mucosal defects involving ≥75% of the esophageal circumference were randomized to receive a single dose of triamcinolone acetonide injections (n = 16) or be treated conventionally (n = 16). The primary outcome was the frequency of stricture requiring endoscopic dilatation; the surrogate primary endpoint was the number of dilatation sessions needed. Secondary outcomes included adverse event rates, the minimum diameter of the stenotic area and the duration of the course of dilatation treatments.

RESULTS

The frequency of stricture was not significantly different between the groups because of insufficient statistical power, but the number of dilatation sessions required was significantly less in the steroid group (6.1 sessions [95% confidence interval, CI 2.8-9.4] versus 12.5 [95% CI 7.1-17.9] sessions in the control group; P = 0.04). The perforation rate was similar in both groups. The minimum diameter of stenotic lumens was significantly greater in the treatment group than controls (11.0 mm versus 7.1 mm, respectively; P = 0.01). The perforation rate was not significantly different between the groups (1.0% versus 0.5% in the treatment and control group, respectively). Steroid injection was effective in cases of mucosal defects encompassing the entire esophageal circumference.

CONCLUSIONS

Prophylactic endoscopic steroid injection appears to be a safe means of relieving the severity of esophageal stenoses following extensive ESD.

Complications of endoscopic dilation for esophageal stenosis after endoscopic submucosal dissection of superficial esophageal cancer

BACKGROUND

Endoscopic dilation (ED) is used for the treatment of benign strictures caused by reflux esophagitis or anastomotic stenosis after esophagectomy. Esophageal stenosis is a major complication after endoscopic submucosal dissection (ESD) of large superficial esophageal cancer, but little is known regarding the incidence of complications of ED for stenosis caused by esophageal ESD.

METHODS

This was a retrospective study conducted at a single institution. From September 2002 to December 2012, a total of 1,337 ED procedures were performed for stenosis after esophageal ESD in 121 patients. The incidence of complications of ED and related clinical characteristics were analyzed.

RESULTS

The incidence of bleeding was 0.8 % (1/121) per patient and 0.07 % (1/1,337) per procedure. The incidence of perforation was 4.1 % (5/121) per patient and 0.37 % (5/1,337) per procedure. Perforation occurred at a median of third time of ED procedures (range 2-9 procedures) and at a median of 18 days (range 8-29 days) after ESD. There were no significant characteristics correlated to perforation, such as location, circumferential extent, or diameter of mucosal defect after ESD. The total number of ED procedures was significantly larger among perforation cases (37, range 6-57) compared with those without perforation (7, range 1-70) (p = 0.01), and the treatment duration tended to be longer (190 vs. 69 days, respectively).

CONCLUSIONS

The incidence of bleeding caused by ED for esophageal stenosis after ESD was very low. Relevant risk of perforation should be considered for patients requiring multiple ED procedures.

Stricture occurring after endoscopic submucosal dissection for esophageal and gastric tumors

Endoscopic submucosal dissection (ESD) is a widely accepted treatment for early gastric and esophageal cancer. Compared to endoscopic mucosal resection, ESD has the advantage of enabling en bloc removal of tumors regardless of their size. However, ESD can result in a large artificial ulcer, which may lead to a considerable deformity. Circumferential mucosal defects of more than three-fourths the esophageal circumference, long longitudinal mucosal defects (>30 mm), and lesions in the upper esophagus are significant risk factors for the development of post-ESD strictures of the esophagus. In the stomach, a circumferential mucosal defects more than three-fourths in extent and longitudinal mucosal defects >5 cm are risk factors of post-ESD stricture. If scheduled early, regular endoscopic balloon dilation is effective in controlling and preventing post-ESD stricture. Moreover, intralesional steroid injections or oral steroids can achieve remission of dysphagia or reduce the need for repeated endoscopic balloon dilation. However, further study is needed to improve the prevention of stricture formation.

Prevention of esophageal strictures after endoscopic submucosal dissection

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have recently been accepted as less invasive methods for treating patients with early esophageal cancers such as squamous cell carcinoma and dysplasia of Barrett’s esophagus. However, the large defects in the esophageal mucosa often cause severe esophageal strictures, which dramatically reduce the patient’s quality of life. Although preventive endoscopic balloon dilatation can reduce dysphagia and the frequency of dilatation, other approaches are necessary to prevent esophageal strictures after ESD. This review describes several strategies for preventing esophageal strictures after ESD, with a particular focus on anti-inflammatory and tissue engineering approaches. The local injection of triamcinolone acetonide and other systemic steroid therapies are frequently used to prevent esophageal strictures after ESD. Tissue engineering approaches for preventing esophageal strictures have recently been applied in basic research studies. Scaffolds with temporary stents have been applied in five cases, and this technique has been shown to be safe and is anticipated to prevent esophageal strictures. Fabricated autologous oral mucosal epithelial cell sheets to cover the defective mucosa similarly to how commercially available skin products fabricated from epidermal cells are used for skin defects or in cases of intractable ulcers. Fabricated autologous oral-mucosal-epithelial cell sheets have already been shown to be safe.

Long-term outcome after endoscopic submucosal dissection in patients with superficial esophageal squamous cell carcinoma: a single-center study

BACKGROUND/AIMS

Superficial esophageal squamous cell carcinoma (SESCC) is being increasingly detected during screening endoscopy. Endoscopic submucosal dissection (ESD) allows for en bloc and histologically complete resection of lesions. This study assessed the technical feasibility and long-term outcomes of ESD for SESCCs.

METHODS

Between January 2005 and August 2012, 27 patients with 28 SESCCs underwent ESD at Pusan National University Hospital. The en bloc and pathologically complete resection rates, complication (perforation and bleeding) rate, incidence of esophageal stricture after ESD, and overall and disease-specific survival rates were evaluated.

RESULTS

The en bloc and pathologically complete resection rates were 93% and 83%, respectively. No significant bleeding occurred, and perforation with mediastinal emphysema was observed in two patients (7%). Post-ESD stricture occurred in two patients (7%) who had mucosal defects involving more than three-fourths of the esophageal circumference. During a mean follow-up of 23 months, local tumor recurrence was seen in two of four lesions with pathologically incomplete resection; one was treated by re-ESD, and the other was treated by surgical esophagectomy. The 5-year overall and disease-specific survival rates were 84% and 100%, respectively.

CONCLUSIONS

ESD seems to be a feasible, effective curative treatment for SESCCs. All patients should be closely followed after ESD.

Endoscopic submucosal dissection for malignant esophageal lesions

The incidence of esophageal cancer has been increasing while the prognosis remains very poor. Endoscopic submucosal dissection (ESD) was developed in Japan for en bloc resection of early gastric cancer with excellent results. The use of ESD in early squamous cell cancer (SCC) of the esophagus in Japan has been increasing with long-term results comparable to those in early gastric cancer. The use of ESD in Barrett's neoplasia in western countries has been challenged by the low complete resection rates and the risk of metachronous lesions from surrounding non-dysplastic Barrett's epithelium. Efforts to combine ESD with other treatment modalities such as radiofrequency ablation in Barrett's neoplasia and chemoradiation in SCC appear to be promising. The use of steroid therapy (local or systemic) has been demonstrated to prevent post-ESD stenosis, which is the most common complication after esophageal ESD.

Prevention and treatment of esophageal stenosis after endoscopic submucosal dissection for early esophageal cancer

Endoscopic submucosal dissection (ESD) for the treatment of esophageal mucosal lesions is associated with a risk of esophageal stenosis, especially for near-circumferential or circumferential esophageal mucosal defects. Here, we review historic and modern studies on the prevention and treatment of esophageal stenosis after ESD. These methods include prevention via pharmacological treatment, endoscopic autologous cell transplantation, endoscopic esophageal dilatation, and stent placement. This short review will focus on direct prevention and treatment, which may help guide the way forward.

Efficacy and safety of endoscopic submucosal dissection for superficial squamous esophageal neoplasia: a meta-analysis

BACKGROUND AND AIMS

Although endoscopic submucosal dissection (ESD) has grown popular in resecting lesions in the stomach, the application of ESD to the esophagus has been limited by greater technical difficulty. An increasing number of series have recently reported the application of ESD to esophageal lesions. The aim of the present systemic review and meta-analysis was to evaluate the efficacy and safety of ESD for esophageal lesions.

METHODS

Comprehensive literature searches (1999-2012) were performed on studies that reported ESD for the removal of esophageal neoplasia. Primary outcome measures were pooled estimates of complete resection rate and en bloc resection rate. Secondary outcome measures were pooled estimates of complication rates.

RESULTS

A total of 15 studies provided data on 776 ESD-treated lesions. The pooled estimate of complete resection rate was 89.4% (95% CI 86.2-91.9%). The pooled estimate of en bloc resection was 95.1% (95% CI 92.6-96.8%). The pooled estimates of complications of ESD such as bleeding, perforation, and stenosis were 2.1, 5.0, and 11.6%, respectively.

CONCLUSIONS

ESD appeared to be an extremely effective technique to achieve complete resection of esophageal neoplasia. The very low rate of complications also shows the potential safety of this approach.

Amniotic membrane grafts for the prevention of esophageal stricture after circumferential endoscopic submucosal dissection

Background and Aims

The prevention of esophageal strictures following circumferential mucosal resection remains a major clinical challenge. Human amniotic membrane (AM) is an easily available material, which is widely used in ophthalmology due to its wound healing, anti-inflammatory and anti-fibrotic properties. We studied the effect of AM grafts in the prevention of esophageal stricture after endoscopic submucosal dissection (ESD) in a swine model.

Animals and Methods

In this prospective, randomized controlled trial, 20 swine underwent a 5 cm-long circumferential ESD of the lower esophagus. In the AM Group (n = 10), amniotic membrane grafts were placed on esophageal stents; a subgroup of 5 swine (AM 1 group) was sacrificed on day 14, whereas the other 5 animals (AM 2 group) were kept alive. The esophageal stent (ES) group (n = 5) had ES placement alone after ESD. Another 5 animals served as a control group with only ESD.

Results

The prevalence of symptomatic strictures at day 14 was significantly reduced in the AM group and ES groups vs. the control group (33%, 40% and 100%, respectively, p = 0.03); mean esophageal diameter was 5.8±3.6 mm, 6.8±3.3 mm, and 2.6±1.7 mm for AM, ES, and control groups, respectively. Median (range) esophageal fibrosis thickness was 0.87 mm (0.78–1.72), 1.19 mm (0.28–1.95), and 1.65 mm (0.7–1.79) for AM 1, ES, and control groups, respectively. All animals had developed esophageal strictures by day 35.

Conclusions

The anti-fibrotic effect of AM on esophageal wound healing after ESD delayed the development of esophageal stricture in our model. However, this benefit was of limited duration in the conditions of our study.

Efficacy and complication of endoscopic submucosal dissection for superficial esophageal carcinoma: a systematic review and meta-analysis

Aim

For patients with superficial esophageal carcinoma, ESD was one of treatment modalities to remove the lesion safely and effectively. We perform this meta-analysis to determine the efficacy and incidence of complication of ESD for patients with superficial esophageal carcinoma.

Method

Articles were searched in MEDLINE (PubMed and Ovid), Cochrane Database of Systemic Reviews, Google scholar, and Web of Science. Two reviewers independently searched and extracted data. Meta-analysis of the efficacy of ESD was analyzed by calculating pooled en bloc and R0 resection rate. Incidence of complications such as perforation, stenosis and mediastinal emphysema was also calculated. Pooling was conducted using either fixed-effects model or random-effects model depending on the heterogeneity across studies.

Results

21 studies (1152 patients and 1240 lesions) were included in this analysis. The pooled en bloc resection rate was 99% (95% CI 99%-100%). Stratified by tumor size, en bloc resection rates did not show any significant difference. The pooled R0 resection rate was 90% (95% CI 87%-93%). The pooled R0 resection rate was 85% (95% CI, 80%-90%) for large tumor and 92% (95% CI, 87%-93%) for small tumor (p < 0.001). Stenosis served as the most common reported complication with pooled incidence of 5% (95% CI 3-8%), followed by perforation (1%, 95% CI 0-1%) and mediastinal emphysema (0% CI 0-1%). The incidence of postoperative stenosis decreased significantly after 2011 (2%, 95% CI 0-3%) compared with that before 2011 (9%, 95% CI 3-8%) (p < 0.001).

Conclusion

ESD was an efficient modality for treating superficial esophageal carcinoma, with perfect en bloc and R0 resection rate and low complication rate. The most common complication of ESD was stenosis. Although recurrence rate was low, patients should be maintained in a scheduled surveillance program.

Endoscopic balloon dilatation for benign esophageal stricture after endoscopic submucosal dissection for early esophageal neoplasms

OBJECTIVE

The aim of this study was to evaluate the safety and efficacy of endoscopic balloon dilatation (EBD) for benign esophageal strictures after ESD for early esophageal neoplasms.

METHODS

Data of 335 patients who were treated with ESD for early esophageal neoplasms from October 2006 to August 2012 were retrospectively reviewed. The characteristics of the patients who underwent EBD for post-ESD stricture were analyzed.

RESULTS

A total of 117 dilatation procedures were performed in 29 patients with post-ESD esophageal stricture. The mean number of EBD sessions was 4.0 (range 1-15) and no complications occurred during the procedures. The median follow-up period for the 29 patients since their last session of EBD was 20 months (range 1-48 months). Of the 28 patients who were followed up for more than 3 months after achieving dysphagia relief, two had recurrent dysphasia and EBD was reintroduced. The treatment success rate was 92.9% (26/28).

CONCLUSION

EBD is a safe and effective modality for the treatment of benign esophageal stricture after ESD for early esophageal neoplasms.

Preventing stricture formation by covered esophageal stent placement after endoscopic submucosal dissection for early esophageal cancer

OBJECTIVE

We aimed to evaluate the efficacy and safety of fully covered esophageal stent placement for preventing esophageal strictures after endoscopic submucosal dissection (ESD).

METHODS

Twenty-two patients with a mucosal defects that exceeded 75 % of the circumference of the esophagus after ESD treatment for superficial esophageal squamous cell carcinomas were grouped according to the type of mucosal defect and randomized to undergo fully covered esophageal stent placement post-ESD (group A, n = 11) or no stent placement (group B, n = 11). In group A, the esophageal stents were removed 8 weeks post-ESD. Endoscopy was performed when patients reported dysphagia symptoms and at 12 weeks post-ESD in patients without symptoms. Savary-Gilliard dilators were used for bougie dilation in patients experiencing esophageal stricture in both groups, and we compared the rates of post-ESD strictures and the need for bougie dilation procedures.

RESULTS

The proportion of patients who developed a stricture was significantly lower in group A (18.2 %, n = 2) than in group B (72.7 %, n = 8) (P < 0.05). Moreover, the number of bougie dilation procedures was significantly lower in group A (mean 0.45, range 0-3) than in group B (mean 3.9, range 0-17) (P < 0.05). The two patients in group A who experienced stricture also had stent displacement.

CONCLUSIONS

Esophageal stents are a safe and effective method of preventing esophageal strictures in cases where >75 % of the circumference of the esophagus has mucosal defects after ESD treatment for early esophageal cancer.

Intralesional steroid injection to prevent stricture after near-circumferential endosopic submucosal dissection for superficial esophageal cancer

Stricture frequently occurs after endoscopic submucosal dissection (ESD) for superficial esophageal carcinoma with near- or whole-circumferential mucosal defects, and post-ESD stricture is difficult to treat and usually requires multiple sessions of endoscopic balloon dilatation. Intralesional steroid injection has previously been used to prevent stricture; however, there have been few experiences with this method after near- or whole-circumferential ESD. We present a case of a single session of intralesional steroid injection performed immediately after near-circumferential ESD to prevent post-ESD stricture. After a follow-up period of 6 months, the patient showed good outcome without dysphagia.

Influence of endoscopic submucosal dissection on esophageal motility

AIM

To assess esophageal motility after esophageal endoscopic submucosal dissection (ESD).

METHODS

Twelve patients (6 men and 6 women) aged 53-64 years (mean age, 58 years) who underwent regular examination 3-12 mo after esophageal ESD for neoplasms of the esophageal body were included in this study. The ESD procedure was performed under deep sedation using a combination of propofol and fentanyl, and involved a submucosal injection to lift the lesion and use of a dual-knife and an insulated-tip knife to create a circumferential incision around the lesion extending into the submucosa. Esophageal motility was examined using a high-resolution manometry system. Dysphagia was graded using a five-point scale according to the Mellow and Pinkas scoring system. Patient symptoms and the results of esophageal manometry were then analyzed.

RESULTS

Of the 12 patients enrolled, 1 patient had grade 2 dysphagia, 1 patient had grade 1 dysphagia, and 3 patients complained of sporadic dysphagia. Ineffective esophageal motility was observed in 5 of 6 patients with above semi-circumference of resection extension. Of these 5 patients, 1 patient complained of grade 2 dysphagia (with esophageal stricture), one patient complained of grade 1 dysphagia, and 3 patients complained of sporadic dysphagia. Normal esophageal body manometry was observed in all 6 patients with below semi-circumference of resection extension. The 6 patients with normal esophageal motility did not complain of dysphagia.

CONCLUSION

Extensive esophageal ESD may cause esophageal dysmotility in some patients, and might also have an influence on dysphagia although without esophageal stricture.

Steroid permeation into the artificial ulcer by combined steroid gel application and balloon dilatation: prevention of esophageal stricture

BACKGROUND AND AIM

Local steroid injection therapy is effective for preventing esophageal stricture after endoscopic submucosal dissection (ESD) but is associated with the risk of puncture-related complications, such as bleeding. We evaluated the effectiveness of the application of triamcinolone acetonide gel following permeation into a large artificial ESD ulcer by balloon dilatation compared with steroid injection.

METHODS

Forty-three patients who underwent ESD for early esophageal cancer approved by the institutional ethics committee and provided consent to participate in this prospective study were divided into two groups using a sealed-envelope randomization method as follows: 23 patients who were treated with local steroid injection and balloon dilatation and 20 patients were treated with steroid application and balloon dilatation. The stricture rate, the number of endoscopic balloon dilatation, and the mean procedure time on postoperative days (PODs) 5, 8, 12, 15, 20, 30, and 60 were analyzed.

RESULTS

No significant difference was found in the stricture rate on PODs 5, 8, 12, 15, 20, 30, and 60 between the two groups. The mean number of endoscopic balloon dilatation procedures performed for treating dysphagia that appeared on or after POD 30 was significantly different between groups (P=0.011). The mean procedure time showed no significant difference. Procedure-related bleeding during the first 30 days was observed more in the local steroid injection group than the gel application group (P=0.02).

CONCLUSIONS

Steroid gel application is an effective way for preventing esophageal stricture after ESD and is more effective compared with local injection in terms of prevention of stricture.

Outcomes of balloon dilation for the treatment of strictures after endoscopic submucosal dissection compared with peptic strictures

BACKGROUND

The outcomes of balloon dilation for the treatment of strictures caused by endoscopic submucosal dissection (ESD) have not been evaluated previously. This study was designed to evaluate and compare the effectiveness and complications of balloon dilation for post-ESD strictures and peptic strictures.

METHODS

The medical records of 14 patients with post-ESD strictures and 48 patients with peptic strictures who underwent fluoroscopically or endoscopically guided balloon dilation between January 1997 and April 2011 at the Asan Medical Center in Korea were reviewed retrospectively.

RESULTS

The technical success rates (defined as successful dilation without major complications) of the post-ESD and peptic stricture groups were 92.9% (13/14) and 93.8% (45/48), respectively (p = 1.000). For the post-ESD and peptic stricture groups, the clinical success rates (defined as symptom improvement, as determined by the patient) at 1 month were 92.9% (13/14) and 83.3% (40/48), respectively (p = 0.67). Their clinical success rates at 6 months were 71.4% (10/14) and 70 % (28/40), respectively (p = 1.000). The mean weight gains of the post-ESD stricture group 1 and 6 months after balloon dilation were 1.1 and 4.8 kg, respectively, whereas the peptic group gained 1.4 and 3.4 kg, respectively (p = 0.814). All complications were perforations. The complication rates of the post-ESD and peptic stricture groups were 7.1 % (1/14) and 10.5 % (5/48), respectively (p = 1.000).

CONCLUSIONS

Balloon dilation is an effective and safe treatment for post-ESD strictures.

Endoscopic radial incision and cutting method for refractory esophageal stricture after endoscopic submucosal dissection of superficial esophageal carcinoma

A 59-year-old woman and a 69-year-old man had esophageal strictures that were refractory to over 10 therapeutic attempts with endoscopic balloon dilation (EBD) after endoscopic submucosal dissections (ESD) for superficial esophageal carcinoma (SEC). The strictured lesions in both patients improved remarkably with a new endoscopic modality (endoscopic radial incision and cutting [ERIC]), which was carried out one to three times, and stricture recurrence was not noted throughout the follow-up period. ERIC is a safe and efficient method for treating refractory strictures after EBD caused by ESD for SEC.

Endoscopic resection (endoscopic submucosal dissection/endoscopic mucosal resection) for superficial Barrett's esophageal cancer

Recently developed endoscopic resection (endoscopic submucosal dissection [ESD]/ endoscopic mucosal resection) has dramatically changed the therapeutic approach for Barrett's esophageal cancer. The rationale for endoscopic resection is that lesions confined to the mucosal layer have negligible risk for developing lymph node metastasis and can be successfully eradicated by endoscopic treatment as a curative treatment with minimal invasiveness. According to some reports that analyzed the rate of lymph-node involvement relative to the depth of mucosal or submucosal tumor infiltration, endoscopic resection is clearly indicated for intramucosal carcinoma and might be extended to lesions with invasion into the submucosa (<200 μm, sm1) because of the low risk for lymph node metastasis. Most Japanese experts recommend ESD for Barrett's esophageal cancer after accurate diagnosis of the margin of cancer using narrow band imaging with magnifying endoscopy because of its high curative rate. However, few studies have evaluated the long-term outcomes of endoscopic resection for Barrett's esophageal cancer in Japan. Further investigations should be conducted to establish endoscopic resection for Barrett's esophageal cancer.

Management of complications associated with endoscopic submucosal dissection/ endoscopic mucosal resection for esophageal cancer

Endoscopic resection of early esophageal cancer (EEC) is an established therapy in Japan and is increasingly becoming accepted and used regularly in other countries. Endoscopic submucosal dissection (ESD), an application of conventional endoscopic mucosal resection (EMR), has been developed to allow the resection of larger lesions in an en bloc manner; the earliest results so far have been promising even in EEC. ESD allows precise assessment of the histopathological curability of resected specimens, reducing local recurrence. However, ESD has relatively high complication rates; notification of perforation risk is essential especially in the esophagus. Bleeding during ESD can be managed by endoscopic closure with endoclips, and delayed bleeding is rare. Esophageal stricture following semicircular or complete circular esophageal ESD was relatively frequent even when treated by multiple pre-emptive endoscopic balloon dilation. Endoscopic triamcinolone injection, temporal stenting and innovative transplantation of autologous tissue-engineered epithelial cell sheets have shown promising results for the prevention of luminal stricture following semicircular esophageal ESD. In cases of circumferential ESD, however, giving oral prednisolone can offer a unique treatment option for the prevention of intractable post-procedural stricture of the esophagus.

Clinical value of preventive balloon dilatation for esophageal stricture

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) were developed for the treatment of benign lesions and early superficial esophageal cancers in the gastrointestinal (GI) tract. However, esophageal strictures frequently develop in patients who undergo EMR/ESD. Therefore, we aimed to investigate the clinical value of preventive balloon dilatation (BD) for esophageal diseases following endoscopic therapy. A total of 30 patients who had received EMR or ESD were enrolled in the study. Preventive BD was carried out for 12 cases within 1 week following EMR/ESD. The remaining 18 cases were not subjected to preventive BD and were used as an historic control. The results revealed that no complications, including esophageal stenosis and dysphagia, were observed in the patients who received preventive BD. In the control group, seven cases experienced dysphagia, of which two were released without clinical treatment and the other five were released following two or three BD procedures. The results indicate that preventive BD is an effective treatment for patients with esophageal diseases following EMR and should be considered at an early stage when the mucosal injury exceeds two-thirds of the esophageal lumen.

A pilot study of scheduled endoscopic balloon dilation with oral agent tranilast to improve the efficacy of stricture dilation after endoscopic submucosal dissection of the esophagus

BACKGROUNDS AND AIM

As circumferential or near-circumferential endoscopic submucosal dissection (ESD) for superficial esophageal neoplasms might evoke refractory strictures, multiple sessions of endoscopic balloon dilation (EBD) are required. We aimed to assess the effectiveness and safety of oral agent tranilast with EBD for improving the efficacy of stricture dilation after esophageal ESD.

METHODS

In an open-label prospective study at a single institution, 31 asymptomatic consecutive patients with superficial esophageal squamous cell carcinomas were enrolled from April 2007 to October 2010. After ESD, we performed scheduled EBD (twice weekly for 4 wk) with or without administration of oral agent tranilast for 8 weeks. Thereafter, we added additional EBD on the basis of solid criteria-for example, patient's awareness of vomiting >1/wk and inability of passage of routine endoscope through the ESD site. We compared the rates of post-ESD strictures and the numbers of additional EBD sessions for 48 weeks after ESD and the Dysphagia score between tranilast (T)-group and none (N)-group, based on patients' subjective symptoms, at 16, 24, and 48 weeks after ESD.

RESULTS

The percentage of post-ESD strictures in T-group was significantly lower than that in N-group (P=0.04). The median numbers of additional EBD sessions and Dysphagia score at 16 and 24 weeks after ESD in T-group were significantly smaller than those in N-group (P=0.0138, 0.002, 0.005, respectively). No adverse events and no recurrence were observed.

CONCLUSIONS

We demonstrated for the first time that scheduled EBD combined with oral agent tranilast might be effective and safe for improving the efficacy of stricture dilation after esophageal ESD.

Reducing complications in upper gastrointestinal endoscopy

This article reviews the principal aspects related to sedation in endoscopy and to the prevention of adverse events in some of the most frequently performed therapeutic upper gastrointestinal (GI) endoscopic procedures (esophageal dilation and stenting, endoscopic resection of upper GI early neoplasia, hemostasis of upper GI bleeding and percutaneous endoscopic gastrostomy insertion). These procedures have an inherent risk of negative outcomes that cannot be entirely avoided. Endoscopic procedures are best performed by well-trained, competent and thoughtful endoscopists in facilities suited to provide for patient safety. Attention to clinical risk management may effectively reduce the frequency and intensity of adverse events, enhance recognition and early detection, and improve responsiveness.

Endoscopic submucosal dissection for superficial esophageal neoplasms

Endoscopic submucosal dissection (ESD) is currently accepted as the major treatment modality for superficial neoplasms in the gastrointestinal tract including the esophagus. An important advantage of ESD is its effectiveness in resecting lesions regardless of their size and severity of fibrosis. Based on excellent outcomes for esophageal neoplasms with a small likelihood of lymph node metastasis, the number of ESD candidates has increased. On the other hand, ESD still requires highly skilled endoscopists due to technical difficulties. To avoid unnecessary complications including perforation and postoperative stricture, the indications for ESD require careful consideration and a full understanding of this modality. This article, in the highlight topic series, provides detailed information on the indication, procedure, outcome, complications and their prevention in ESD of superficial esophageal neoplasms.

Usefulness of endoscopic radial incision and cutting method for refractory esophagogastric anastomotic stricture (with video)

BACKGROUND

There is no effective treatment for gastroesophageal anastomotic strictures that are refractory to repeated endoscopic balloon dilation (EBD). However, EBD is still selected worldwide to manage such refractory strictures. To relieve the symptoms of dysphagia and keep a wide lumen, we developed a new incisional treatment, radial incision and cutting (RIC).

OBJECTIVE

To evaluate the efficacy and safety of the RIC method for the treatment of refractory anastomotic strictures.

DESIGN

Retrospective cohort study.

SETTING

National Cancer Center and University Hospital.

PATIENTS

This study involved 54 consecutive patients with refractory anastomotic stricture after esophagogastric surgery.

INTERVENTION

RIC.

MAIN OUTCOME MEASUREMENTS

The safety and clinical success of RIC and the long-term patency after RIC compared with those of continued EBD.

RESULTS

The median procedure time of RIC was 14 minutes (range, 4-40 minutes). No serious adverse events associated with RIC were observed. Immediately after RIC, 81.3% (26/32) of patients were able to eat solid food without symptoms of dysphagia. As a short-term effect, the dysphagia improved after RIC in 93.8% (30/32) of the patients. As a long-term effect, 63% (17/27) and 62% (13/21) of patients were able to eat solid food 6 and 12 months after RIC, respectively. The 6-month and 12-month patency rates were significantly different between the RIC group and the continued EBD group (65.3% vs 19.8%, P < .005; 61.5% vs 19.8%, P < .005).

LIMITATIONS

Nonrandomized retrospective study.

CONCLUSIONS

RIC is an effective and safe method. The demonstration of the validity of this method may place RIC as a new medical treatment for patients with refractory stricture after surgical resection for esophagogastric diseases.

Endoscopic submucosal dissection for treatment of esophageal submucosal tumors originating from the muscularis propria layer

BACKGROUND

The technique of endoscopic submucosal dissection (ESD), which was developed for en bloc resection of large lesions in the stomach, has been widely accepted for the treatment of early gastric cancer. It is being used for muscularis propria tumors of the digestive tract and has produced positive therapeutic effects.

OBJECTIVE

To study the feasibility of ESD for the removal of esophageal muscularis propria tumors and to evaluate the efficacy and safety of ESD for this treatment.

DESIGN

Single-center, retrospective study.

SETTING

University hospital.

PATIENTS

Thirty esophageal muscularis propria tumors from 28 patients were treated with ESD between December 2008 and December 2010. We defined esophageal muscularis propria tumors as esophageal submucosal tumors originating from the muscularis propria layer.

INTERVENTION

ESD.

MAIN OUTCOME MEASUREMENTS

Tumor characteristics, complications, en bloc resection rate, and local recurrence rate were evaluated.

RESULTS

Among the 28 patients, 11 were women (39.3%). The median age was 49.32 years (range 22-62 years). Mean (± SD) tumor size was 1.25 ± 0.70 cm (range 0.5-3.0 cm). Except for 2 failed cases (one changed to surgery and the other changed to nylon ligation), 26 cases with 28 tumors (2 cases had 2 tumors) originating from the muscularis propria of the esophagus were successfully resected by ESD. The en bloc resection rate was 93.3% (28/30). The median ESD procedure time was 73.5 minutes (range 30-120 minutes). Perforation occurred in 2 cases during dissection of the lesion, which was closed with metal endoclips. Pneumothorax occurred after the treatment in both cases. Closed thoracic drainages were initiated, and the patients recovered quickly without surgery. Pathological examination confirmed 27 leiomyomas and 1 GI stromal tumor. The curative resection rate was 100% (28/28). There was no recurrence during a 3 to 27-month follow-up period.

LIMITATIONS

The limitation of the study was its retrospective design.

CONCLUSION

ESD offers the promise of localized treatment of esophageal muscularis propria tumors with relatively few complications and low mortality. It makes the resection of whole lesions possible and provides precise histologic information.

Efficacy and safety of EMR to completely remove Barrett's esophagus: experience in 41 patients

BACKGROUND

EMR is typically used to remove focal abnormalities of the esophageal mucosa. However, larger areas of Barrett's esophagus (BE) can be resected through side-by-side resections.

OBJECTIVE

To assess the efficacy and safety of EMR to completely remove BE.

DESIGN

Retrospective, single-center study.

SETTING

University of Iowa Hospitals and Clinics.

PATIENTS

Between January 2006 and December 2010, 46 patients underwent EMR for complete removal of BE. Three were lost to follow-up, one died of unrelated causes before completion, and one was still undergoing EMR treatment at the conclusion of the study. The remaining 41 patients were included for analysis. The worst histologic grade was low-grade dysplasia in 4 patients, high-grade dysplasia without cancer in 26 patients, and high-grade dysplasia with superficial adenocarcinoma in 11 patients. BE was circumferential in 65.9% of cases, and the mean (± SD) length was 3.3 ± 2.3 cm.

INTERVENTION

EMR was performed by using a cap (n = 4), a multiband ligator device (n = 31), or both (n = 6), with a mean (± SD) of 2.4 ± 1.2 sessions per patient.

MAIN OUTCOME MEASUREMENTS

Remission rates and complications.

RESULTS

Remission of high-grade dysplasia and cancer, all dysplasia, and all BE was achieved in 94.6%, 85.4%, and 78.0%, respectively. Complications included minor bleeding (31.7%), perforations (4.9%), and strictures (43.9%). All complications were managed conservatively.

LIMITATIONS

Retrospective design.

CONCLUSION

Complete removal of BE with EMR is effective but associated with a high complication rate, which is mainly related to stricture formation. This needs to be considered when choosing between available treatment modalities.

Endoscopic resection techniques and ablative therapies for Barrett's neoplasia

Esophageal adenocarcinoma is the most rapidly increasing cancer in western countries. High-grade dysplasia (HGD) arising from Barrett's esophagus (BE) is the most important risk factor for its development, and when it is present the reported incidence is up to 10% per patient-year. Adenocarcinoma in the setting of BE develops through a well known histological sequence, from non-dysplastic Barrett's to low grade dysplasia and then HGD and cancer. Endoscopic surveillance programs have been established to detect the presence of neoplasia at a potentially curative stage. Newly developed endoscopic treatments have dramatically changed the therapeutic approach of BE. When neoplasia is confined to the mucosal layer the risk for developing lymph node metastasis is negligible and can be successfully eradicated by an endoscopic approach, offering a curative intention treatment with minimal invasiveness. Endoscopic therapies include resection techniques, also known as tissue-acquiring modalities, and ablation therapies or non-tissue acquiring modalities. The aim of endoscopic treatment is to eradicate the whole Barrett's segment, since the risk of developing synchronous and metachronous lesions due to the persistence of molecular aberrations in the residual epithelium is well established.

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) in 2011, a Western perspective

Endoscopic mucosal resection (EMR) has become the standard of care for removal of large flat and sessile neoplastic lesions of the GI tract. Recently, endoscopic submucosal dissection (ESD) was introduced in Japan as an alternative technique, which allows en bloc resection of large lesions. The applications of EMR and ESD are expanding and many Western endoscopists are adopting these techniques. Paris classification and Kudo pit pattern classification allows prediction of the depth of invasion of early neoplastic lesions and thus, avoids resection of lesions invading the deep submucosa which have higher rates of lymphatic spread. ESD of early stomach cancer is the standard of care in Japan. Recent published reports from Western countries showed comparable results for ESD of early gastric cancers to those done in Japan. Recently, EMR combined with ablation has been used frequently in Western countries for treatment of high-grade dysplasia in early adenocarcinoma of the esophagus. Although ESD of early neoplastic lesions of the esophagus is technically difficult, few promising reports were published proving the feasibility of this technique in the West. ESD has been shown to achieve higher en bloc resection and lower rates of tumour recurrence in removal of lateral spreading colonic polyps. A hybrid technique of circumferential submucosal incision followed by en bloc EMR has been used for removal of large colonic lesions in some Western endoscopy centres. In Western countries, training for ESD is challenging given the lack of training in the relatively easier early gastric cancer lesions. Animal model training combined with observing experts in ESD could be an alternative for Western endoscopists. Inspite of obstacles, ESD applications are continuing to grow in Western countries.