Steroid pulse therapy prevents restenosis following balloon dilatation for esophageal stricture

H2S attenuates oxidative stress via Nrf2/NF-κB signaling to regulate restenosis after percutaneous transluminal angioplasty

Restenosis after angioplasty of peripheral arteries is a clinical problem involving oxidative stress. Hydrogen sulfide (H2S) participates in oxidative stress regulation and activates nuclear factor erythroid 2-related factor 2 (Nrf2). This study investigated the effect of H2S and Nrf2 on restenosis-induced arterial injury. Using an in vivo rat model of restenosis, we investigated whether H2S inhibits restenosis after percutaneous transluminal angioplasty (PTA) and the oxidative stress-related mechanisms implicated therein. The involvement of Nrf2 was explored using Nrf2-shRNA. Neointimal formation and the deposition of elastic fibers were assessed histologically. Inflammatory cytokine secretion and the expression of proteins associated with oxidative stress and inflammation were evaluated. The artery of rats subjected to restenosis showed increased arterial intimal thickness, with prominent elastic fiber deposition. Sodium hydrosulfide (NaHS), an H2S donor, counteracted these changes in vivo. Restenosis caused a decrease in anti-oxidative stress signaling. This phenomenon was inhibited by NaHS, but Nrf2-shRNA counteracted the effects of NaHS. In terms of inflammation, inflammatory cytokines were upregulated, whereas NaHS suppressed the induced inflammatory reaction. Similarly, Nrf2 downregulation blocked the effect of NaHS. In vitro studies using aortic endothelial and vascular smooth muscle cells isolated from experimental animals showed consistent results as those of in vivo studies, and the participation of the nuclear factor-kappa B signaling pathway was demonstrated. Collectively, H2S played a role in regulating post-PTA restenosis by alleviating oxidative stress, modulating anti-oxidant defense, and targeting Nrf2-related pathways via nuclear factor-kappa B signaling.

Efficacy of and prognosis after steroid pulse therapy in patients with poor reduction of jaundice after laparoscopic Kasai portoenterostomy

PURPOSE

High-dose postoperative steroid therapy after Kasai portoenterostomy is reported to improve jaundice clearance and a strong anti-inflammatory activity might prevent fibrous tissue formation which is often observed at the porta hepatis in revision surgery. We started steroid pulse therapy for the patients with cessation of decrease in jaundice and aimed to evaluate the efficacy in this study.

METHODS

The demographics and outcomes of patients who underwent laparoscopic Kasai portoenterostomy and received steroid pulse therapy within 2 months postoperatively between September 2014 and December 2018 were retrospectively reviewed; the therapy was determined successful when the serum total bilirubin level decreased to or below two-thirds of the pre-therapy level after 2 weeks. Patient data in the successful group were compared with those in the unsuccessful group.

RESULTS

Steroid pulse therapy was successful in seven of 16 patients (43.8%). The percentage of patients whose serum total bilirubin level decreased to normal was significantly higher in the successful group at 3 months (85.7% vs. 11.1%, P = 0.0028) and after all (100% vs. 33.3%, P = 0.011).

CONCLUSIONS

Steroid pulse therapy was effective for some patients. Unsuccessful cases may have little chances of jaundice clearance; revision Kasai portoenterostomy would be a good option.

Corrosive Esophageal Injury due to a Commercial Vinegar Beverage in an Adolescent

Although gastroesophageal damage is commonly induced by accidental drinking of a strong acid or alkali, damage due to the consumption of a vinegar beverage is not well known. We report a case of corrosive esophageal ulcer found in an adolescent consuming a vinegar drink daily. A 15-year-old male visited the emergency room presenting with hematemesis and severe epigastric pain. Multiple longitudinal ulcers, concurrent mucosal hemorrhage, and denuded mucosa were noted in the whole of the esophagus via an endoscopic examination. He had been drinking a vinegar beverage daily without sufficient dilution. The patient was treated with corticosteroid, antibiotic therapy, and mucosa protecting alginate medication and was asked to fast for a week. The follow-up endoscopy showed improvement of the esophageal injuries. Overall, continuous consumption of a vinegar beverage can result in acidic burns and destruction of the surface of the upper gastrointestinal tract. Therefore, vinegar beverages should be considered as corrosive agents.

Mucosal loss as a critical factor in esophageal stricture formation after mucosal resection: a pilot experiment in a porcine model

BACKGROUND AND AIM

Esophageal stricture is a major complication of large areas endoscopic submucosal dissection (ESD). Until now, the critical mechanism of esophageal stricture remains unclear. We examined the role of mucosal loss versus submucosal damage in esophageal stricture formation after mucosal resection using a porcine model.

MATERIALS AND METHODS

Twelve swine were randomly divided into two groups, each of 6. In each group, two 5-cm-long submucosal tunnels were made to involve 1/3rd of the widths of the anterior and posterior esophageal circumference. The entire mucosal roofs of both tunnels were resected in group A. In group B, the tunnel roof mucosa was incised longitudinally along the length of the tunnel, but without excision of any mucosa. Stricture formation was evaluated by endoscopy after 1, 2, and 4 weeks, respectively. Anatomical and histological examinations were performed after euthanasia.

RESULTS

Healing observed on endoscopy in both groups after 1 week. Group A (mucosa resected) developed mild-to-severe esophageal stricture, dysphagia, and weight loss. In contrast, no esophageal stricture was evident in group B (mucosa incisions without resection) after 2 and 4 weeks, respectively. Macroscopic examination showed severe esophageal stricture and shortening of esophagus in only group A. Inflammation and fibrous hyperplasia of the submucosal layer was observed on histological examination in both groups.

CONCLUSION

The extent of loss of esophageal mucosa appears to be a critical factor for esophageal stricture. Inflammation followed by fibrosis may contribute to alteration in compliance of the esophagus but is not the main mechanism of postresection stricture.

Comparison of outcomes of thoracoscopic primary repair of gross type C esophageal atresia performed by qualified and non-qualified surgeons

PURPOSE

Although thoracoscopic repair of esophageal atresia has become widespread, most studies are based on operations performed by expert surgeons. Therefore, the outcomes of operations performed by non-expert surgeons are not well known. The aim of this study was to compare outcomes based on operator skill level.

METHODS

We retrospectively reviewed the demographics and outcomes of patients with Gross type C esophageal atresia, who underwent primary thoracoscopic repair at our hospital between January 2014 and August 2016. Outcomes of surgeries performed by qualified surgeons, as determined by the Japanese Society for Endoscopic Surgery were compared with those of non-qualified surgeons. All operations were performed by or under the supervision of one qualified surgeon.

RESULTS

Nine operations were performed by qualified surgeons and six operations by non-qualified surgeons with >10 years of experience in surgery. None of the patients developed anastomotic leakage or recurrent tracheoesophageal fistula. However, the operative time and rate of stricture formation at the beginning of the weaning period were significantly higher in the latter group (P = 0.008 and 0.044).

CONCLUSIONS

Although supervision of experts would improve results in thoracoscopic repair of esophageal atresia, the results indicate that good skill is necessary to avoid anastomotic stricture.

Surveillance in Patients With Esophageal Atresia/Tracheoesophageal Fistula

PURPOSE OF REVIEW

Esophageal atresia/tracheoesophageal fistula (EA/TEF) is a congenital aerodigestive anomaly with high survival rates after surgical repair. Care should now be focused on prevention of long-term complications using appropriate surveillance techniques.

RECENT FINDINGS

The incidence of gastroesophageal reflux disease (GERD) is high in patients with EA/TEF. Consequences of untreated GERD include esophagitis, strictures, and Barrett esophagus. Subjective symptoms are an unreliable indicator of presence or severity of GERD, and therefore, diagnostic testing is needed to assess esophageal heath and monitor the effectiveness of anti-reflux treatment. Esophagogastroduodenoscopy with biopsy remains the primary surveillance tool, but is invasive and not without risks. Less-invasive modalities such as multichannel intraluminal impedance and pH monitoring to assess GERD appear to correlate strongly with esophageal histology and may provide sufficient information to guide treatment. EA/TEF patients face numerous challenges that need to be considered. Routine surveillance protocols and close monitoring are warranted to assess complications. Further research is needed to delineate the frequency of esophagogastroduodenoscopy versus less-invasive and promising modalities such as multichannel intraluminal impedance-pH monitoring.