Introduction

Balloon dilation is sometimes required to prevent stricture after esophageal endoscopic submucosal dissection (ESD), but the procedure is performed frequently and there is a risk of perforation.

Aims & Methods

In this study, we investigated whether intensive triamcinolone (TA) injection after extensive esophageal ESD can prevent stricture while avoiding balloon dilation. Thirty-one lesions in 31 patients with post ESD ulcers more than 3/4 circumference and confirmed scarring from December 2017 to February 2023 were included in this study. The total circumferential resection was defined as group A, the other group as group B, and stricture was defined as the inability to pass an endoscope of normal diameter (8.9-10.2 mm). All patients underwent TA immediately after ESD. Basically, after ESD, weekly TA injection was performed in group A, and no additional injection/ weekly or bi-weekly TA injection was performed in group B, depending on the endoscopists’ judgement. The primary endpoint was the percentage of patients who required balloon dilation, and the secondary endpoints were the stricture rate and the number of TA injections.

Results

Group A (8 patients, 8 lesions) and Group B (23 patients, 23 lesions). Morphology (IIa/IIb/IIc) 0/1/7, 1/4/18. Histological type (squamous cell carcinoma / Barrett's esophageal adenocarcinoma) 7/1, 22/1, and en bloc resection rate was 100% in both groups. No perforation was observed in either group. Three consecutive patients (37.5%) in the early stage of group A and three consecutive patients (13.0%) in early stage of group B were treated with oral steroids. The length of resection (mm) (median (range)) were 55 (40-80) and 50 (40-120), respectively, and the circumferential length (mm) was 30 (20-50) in group A. The longest observation period until the presence of stricture was 15 (1-38)/11 (1-37) months, respectively. The percentage of balloon dilation required and the stricture rate (n (%)) were both 0 (0) in group A and 1 (4.3) in group B. The number of TA injections was 8 (3-12) and 1 (1-3), significantly higher in group A (p < 0.01. Mann-Whitney U test). One case in group B required balloon dilation because of difficulty in coming to the hospital due to poor ADL after a subcircumferential resection, and the additional injection was performed 3 weeks after ESD, later than scheduled.

Conclusion

Intensive TA injection based on weekly or bi-weekly was effective in preventing stricture after extensive esophageal ESD, and could avoid balloon dilation even in cases with circumferential resection.

Introduction

This study aimed to compare the efficacy of combined intravenous and oral proton pump inhibitor (PPI) versus oral vonoprazan (VPZ) alone therapy in preventing delayed bleeding (DB) after gastric endoscopic submucosal dissection (ESD) in a consecutive and large case series.

Aims & Methods

A retrospective study at Chiba University Hospital included consecutive patients who underwent gastric ESD between January 2017 and July 2023. Before 2019, patients received intravenous omeprazole 20 mg in the morning and evening on the day of ESD and the day after. Thereafter, esomeprazole 20 mg was administered orally once daily, which was continued for generally 28 days (defined as the PPI group). From 2020 onward, patients received oral VPZ 20 mg once daily starting on the day of ESD, also typically continued for 28 days (defined as the VPZ group). Propensity score generation and 1:1 matching of patients between the PPI and VPZ groups were performed to minimize selection bias in treatment assignment. Matching was based on nine covariates associated with DB rates for gastric ESD, including whether patients were taking warfarin, directly acting oral anticoagulant (DOAC), P2Y12 receptor antagonist, aspirin, or cilostazol; whether it was CKD with haemodialysis, a tumour size >30 mm, lower-third in tumour location and presence of multiple tumours.

Results

There were 720 cases (856 tumors) of gastric ESD during the study period, of which 352 (409 tumors) were in the PPI group and 368 (447 tumors) in the VPZ group. Propensity score matching for 9 covariates related to DB rates for gastric ESD ultimately produced 334 best matches. There was no significant difference in DB rates between the two groups (3.6% vs 3.6%. p = 1.000).

Conclusion

Though further prospective studies are needed to draw definitive conclusions, it was suggested that the easily administered oral VPZ can be an important option for acid suppression after gastric ESD.

Introduction

There is no consensus on preoperative endoscopic diagnostic methods for superficial nonampullary duodenal tumor (SNADET). We previously reported that texture and color enhanced imaging (TXI) with indigocarmine (ICME-TXI) significantly improved the visibility of SNADET surface structures compared to narrow band imaging (Sci Rep 2022).

Aims & Methods

In this study, we aimed to investigate the diagnostic ability of ICME-TXI. Forty-six consecutive lesions that were endoscopically resected and pathologically neoplastic after prospective ICME-TXI observation for SNADET from March 2021 to November 2022 were included. The components of the surface structure were classified as circular, oval, or others. The presence of both heterogeneity (mixture of components or difficulty in visualization) and size difference (difference of 3 times or more in size with areas of components) were defined as significant findings. Immunohistochemical staining was performed to clarify whether tumor was gastric, intestinal or mixed type. ICME-TXI image and pathological findings were compared. In addition, the diagnostic ability of the lesions was retrospectively evaluated against the Vienna Classification (VCL) C4/5.

Results

Major morphology (Is/ Ip/ IIa/ IIc) = 8/ 2/ 32/ 4, median tumor diameter (mm) = 10 (3-40), location (bulb 9 lesions/ descending 37 lesions), CSP 15 lesions, UEMR 31 lesions, VCL C3 39 lesions, C4/5 7 lesions, gastric/ intestinal/ mixed type=2/ 36/ 8, respectively. 100% of gastric, 0% of intestinal and 37.5% of intestinal type had a circular component. 4 lesions (8.7%) had histopathological findings similar to traditional serrated adenoma (TSA) of the colon and were characterized by an oval component (all were intestinal type, VCL C3). The sensitivity/ specificity/ positive predictive value/ negative predictive value/ accuracy (%) for VCL C4/5 were 57.1/ 94.5/ 66.7/ 92.5/ 89.1.

Conclusion

ICME-TXI revealed fine surface structures, and showed specific findings for a particular histological type similar to TSA. The high specificity and negative predictive value of ICME-TXI for preoperative diagnosis suggest that ICME-TXI may be a new diagnostic modality.

References

1. Okimoto K, Matsumura T, Maruoka D et al. Magnified endoscopy with texture and color enhanced imaging with indigo carmine for superficial nonampullary duodenal tumor: a pilot study. Sci Rep 2022; 12: 10381

Introduction

Endoscopic submucosal dissection (ESD) is the standard treatment for superficial esophageal cancer. However, esophageal stricture following endoscopic ESD is a common and severe complication, leading to malnutrition, increased financial burden, and reduced quality of life.

Aims & Methods

This study aimed to develop a risk prediction model for stricture after non-circumferential ESD to improve prevention, treatment, and personalized management of post-ESD esophageal stricture. Clinical data were retrospectively collected from patients with suspected early esophageal squamous cell carcinoma undergoing ESD between January 2014 and December 2022 at four tertiary hospitals in Sichuan Province, China.
Cases were divided into non-circumferential and circumferential ESD groups. Non-circumferential ESD cases were split into a development cohort (70%) and a validation cohort (30%). Independent risk factors for stricture were identified using univariate and multivariate logistic regression analyses. A risk scoring model was established and internally validated.
For patients with circumferential lesions, a case-control study was first conducted to validate the efficacy of steroid-based interventions in reducing ​stricture​ rates, followed by subgroup analyses comparing the therapeutic differences between oral administration alone and oral combined with local injection.

Results

Among 2009 enrolled patients, the stricture rate was 12.9% (259/2009). Data from 1854 non-circumferential ESD cases were used for model construction. Independent risk factors included wound circumferential extent, lesion location, intraoperative titanium clip usage, and non-R0 resection. The risk stratification model (score range: 0–8) categorized patients into low- (0–2 points, 1.7% stricture), intermediate- (3–5 points, 25%), and high-risk (6–8 points, 80%) groups. In the validation cohort, the model demonstrated an AUC of 0.864 (95% CI: 0.814–0.914, P<0.001), Hosmer-Lemeshow test (P=0.187), and Brier score of 0.0456, indicating excellent discrimination and calibration (Table 1）.
Among 155 patients undergoing circumferential esophageal ESD, the stricture rate was 72.9% (113/155). The stricture rate was 100% (14/14) in the non-steroid group versus 70.2% (99/141) in the steroid group (P=0.017). Patients receiving steroids required an average of 7.4 ± 8.9 dilation sessions, which was significantly lower than the non-steroid group (P=0.031). Nevertheless, no significant differences were observed between oral steroids alone and combined oral with local injection steroids in preventing strictures (P=0.908) or reducing dilation sessions (P=0.652).
Table 1. Predictive Scoring System for Post-ESD Stricture (Non-Circumferential Lesions）

Conclusion

This multicenter study identified ​​wound circumferential extent, lesion location, titanium clip use, and non-R0 resection​​ as independent risk factors for stricture after non-circumferential ESD. A validated ​​risk stratification model (low/intermediate/high-risk)​​ enables tailored postoperative management. While steroids reduced strictures in circumferential ESD, ​​oral versus combined oral/local injection regimens​​ showed no difference in efficacy or dilation frequency.

References

1. Pimentel-Nunes P, Libânio D, Bastiaansen B A J, et al. Endoscopic submucosal dissection for superficial gastrointestinal lesions: European society of gastrointestinal endoscopy (ESGE) guideline - update 2022[J]. Endoscopy, 2022, 54(6): 591-622.
2. Park C H, Yang D H, Kim J W, et al. Clinical practice guideline for endoscopic resection of early gastrointestinal cancer[J]. Intestinal Research, 2021, 19(2): 127-157.
3. Ishihara R, Arima M, Iizuka T, et al. Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer[J]. Digestive Endoscopy, 2020, 32(4): 452-493.
4. Kitagawa Y, Uno T, Oyama T, et al. Esophageal cancer practice guidelines 2017 edited by the japan esophageal society: Part 2[J]. Esophagus, 2019, 16(1): 25-43.

Introduction

Esophageal anastomotic stricture is a common complication after esophagogastric anastomosis, primarily characterized by inability to eat or difficulty swallowing.

Aims & Methods

This study aims to compare the efficacy and safety of endoscopy radial incision (ERI) technique versus endoscopic balloon dilation (EBD) in treating refractory esophageal anastomotic strictures. A retrospective analysis was conducted on patients who underwent endoscopic treatment for esophageal anastomotic stricture from January 2020 to June 2024. Based on inclusion and exclusion criteria, data were collected and analyzed, including preoperative stricture duration, preoperative treatment history, pre-and postoperative swallowing difficulty symptoms (Barthe score), improvement in anastomotic diameter, and occurrence of intraoperative and postoperative complications, to assess efficacy and safety.

Results

A total of 109 patients were included in the study, with 46 in the ERI group and 63 in the EBD group. All patients successfully completed the endoscopic procedures. The average operation time for the ERI group was 10.15±5.23 minutes, with an average of 2.26±0.76 incisions made. No adverse events such as bleeding or perforation occurred in either group during or after the procedure. There were no significant differences in preoperative dysphagia score (3.58±0.76 vs. 3.22±0.63) or anastomotic diameters (0.30±0.02 vs. 0.29±0.03) between the two groups. On postoperative 1 week, 3 months, 6 months, and 1 year, the effective symptom relief rates for the ERI group were 100%, 76.1%, 47.8%, and 41.3%, respectively, while the effective symptom relief rates for the EBD group were 100%, 39.7%, 28.6%, and 20.6%.

Conclusion

The ERI technique is a safe and feasible method for treating refractory esophageal anastomotic strictures, with superior efficacy compared to EBD.

Introduction

The causes of most esophageal motility disorders (EMDs) remain unknown. Recent reports have suggested a potential association between achalasia and varicella zoster virus (VZV) reactivation. Salivary detection of VZV DNA is recognized as a potential diagnostic marker for herpes zoster and enteric zoster. If a correlation between salivary VZV DNA and VZV antibodies and EMDs is demonstrated, it could provide new insights into the pathogenesis of EMDs.

Aims & Methods

This study aimed to investigate the relationship between various EMDs and VZV infection.
This was cross-sectional study. The participants in this study underwent high-resolution manometry (HRM) at our hospital between 2022 and 2024. Saliva and blood samples were collected from all patients. The presence of VZV DNA in the saliva was determined using nested polymerase chain reaction (PCR) and electrophoresis. VZV-immunoglobulin M and immunoglobulin G antibody titers were measured in the blood samples. Based on the HRM results, the patients were divided into an EMD group and a normal group. The results were compared between these groups.

Results

A total of 72 patients were included. Of these, 32 (44.4%) were in the normal group and 40 (55.6%) were in the EMD group, including 22 with esophagogastric junction (EGJ) outflow disorders (achalasia and EGJ outflow obstruction) and 18 with peristalsis disorders (absent contractility, distal esophageal spasm, hypercontractile esophagus, and ineffective esophageal motility). One patient with absent contractility had a concurrent herpes zoster infection, and VZV DNA was detected in this patient’s saliva. However, all other patients tested negative for VZV DNA. No significant difference in VZV antibody titers was observed between the two groups.

Conclusion

This study found no significant differences in the rates of salivary VZV DNA or VZV antibody titers between EMD patients and controls. Given the complex, multifactorial nature of EMDs, further research is warranted to explore alternative mechanisms that may underlie this group of disorders.