Views:5 Author:Site Editor Publish Time: 2019-09-22 Origin:Site
The main complication after ESD is esophageal stenosis.
At present, finding better ways to prevent esophageal stenosis has become a difficult program in the world wide.
Based on this, this paper briefly introduces the factors related with stenosis after ESD operation in large area of early esophageal cancer and analyzes the effect of current prevention measures for stenosis.
Image:complication after ESD
This study contains three parts.
Part I: patients with large area of early esophageal cancer (annular mucosa defective wound ≥3/4 circle) who meet the criteria were selected. Their clinical data were recorded, and we analyze the factors influencing postoperative stenosis.
Part II: all patients included in the study of early esophageal cancer with perioperative resection were immediately placed with covered metal stents to prevent stenosis. The primary outcome of the study was the incidence of stenosis, while the secondary outcome was post-stenosis treatment, stent displacement and postoperative feeding, etc., to analyze the effect of stents on prevention of circumferential stenosis after circumferential resection.
Part III: search the studies and papers on the effect of hormone prevention on ESD postoperative stenosis of early esophageal cancer published until November 2017, and Meta analysis was conducted on the data with RevMan5.3 software.
The results of three parts are presented as below:
Part I: among the 63 patients, 25 patients took preventive measures for stenosis, and totally 32 patients (50.8%) had stenosis. The incidence of stenosis was 38.2% in 34 patients with perioperative mucosal defects ≥3/4 circle to <7/8 circle. The incidence of stenosis was 50.0% in 12 patients with peripheral mucosa defect ≥7/8 circle. The incidence of stenosis was 76.5% in 17 patients with total circumferential resection.
According to univariate and multivariate analysis, the occurrence of large area esophageal stenosis after ESD operation is related to the extent of the defective wound area of mucosa and whether the preventive measures of stenosis is taken.
Part II: Among the 11 cases of total circumferential resection, 8 (72.7%) cases were stenosis. Stent displacement rate was 45.5%. The mean time of stent removal to stenosis was (35.00±12.39) days. Postoperative stenosis occurred in the middle part of the wound. Among the 8 patients with stenosis, 6 patients were successfully treated under endoscope. with an average of 14.17±6.21 times (4 ~ 21 times). The median time from initial treatment to complete remission of stenosis was 9 months (5-60 months).
Part III: a total of 12 studies were included, including 535 patients. Meta analysis showed that local injection of hormone could reduce the incidence of esophageal stenosis after ESD (RR=0.41, 95%ci :0.27 ~ 0.63,P<0.0001). Oral hormone can reduce the incidence of stenosis after partial peripheral ESD (RR=0.25, 95%ci: 0.11-0.54,P=0.0004), but has no significant effect on reducing the incidence of stenosis after complete peripheral ESD (RR=0.54, 95%ci: 0.16-1.84,P=0.33). Both oral hormone (RR=-10.73, 95%ci :-15.47 ~ -5.98,P<0.0001) and local injection of wound hormone (RR=-3.22, 95%ci :-5.11 ~ -1.34,P=0.0008) could reduce the expansion times of EBD after stenosis.
Here we draw the conclusions of three parts study:
Part I :1. The annular mucosa defective wound ≥7/8 circle is the main factor leading to the large area of esophageal stenosis after ESD operation. 2. For patients with postoperative annular mucosal defective wound≥3/4 circle, taking appropriate preventive measures can effectively reduce the incidence of esophageal stenosis after ESD.
Part II: 1. Sole use of fully coated metal stent has certain effect on prevention of esophageal stenosis after ESD operation, with an effective rate of 27.3%(3/11); 2. The fully covered metal stent was unobstructed during placement. After stent removal, the incidence of stenosis was 72.2% (8/11), and the average time from stent removal to stenosis was 35 days. 3. Fully coated metal stent was used to prevent esophageal stenosis, with a high stent displacement rate of 45. 5% (5/11).
Part iii: hormone is safe and effective in preventing esophageal stenosis after ESD; Oral hormone can reduce the incidence of esophageal stenosis after ESD, but has no significant effect on reducing esophageal stenosis after ESD. Both oral hormone and local injection of hormone can reduce the number of times of EBD dilatation after ESD.
Therefore ,we believe that 1. The annular mucosa defective wound ≥7/8 circle is the main factor leading to the stenosis of large area of esophageal early cancer after ESD; 2. The use of fully coated metal stent or hormone to prevent large area of esophageal stenosis after ESD surgery can effectively reduce the incidence of stenosis.
Li zhenjuan. Analysis of influencing factors and prevention of esophageal stenosis after endoscopic submucosal dissection of early esophageal cancer [D]. Chinese people's liberation army medical college, 2018.
Next week we shall introduce the endoscopic therapeutic strategies for esophageal stenosis after ESD.