- Email: [email protected]
The efficacy of endoscopic triamcinolone injection for the prevention of esophageal stricture after endoscopic submucosal dissection
NEW METHODS
The efficacy of endoscopic triamcinolone injection for the prevention of esophageal stricture after endoscopic submucosal dissection Satoru Hashimoto, MD,1 Masaaki Kobayashi, MD,1 Manabu Takeuchi, MD,2 Yuichi Sato, MD,2 Rintaro Narisawa, MD,1 Yutaka Aoyagi, MD2 Niigata, Japan
Background: Use of endoscopic submucosal dissection (ESD) for management of widespread superficial esophageal carcinomas may be complicated by the development of severe strictures, which may require serial treatment with endoscopic balloon dilatation (EBD). Objective: The goal of this study was to determine the efficacy of endoscopic triamcinolone injection (ETI) for the prevention of stricture formation after ESD. Design: Case series. Setting: Tertiary-care referral center. Patients: A total of 41 consecutive patients who had a semi-circumferential mucosal defect that arose after ESD for superficial esophageal squamous cell carcinomas were enrolled in this study. Interventions: EBD and ETI. Main outcome measurements: Incidence of stricture and frequency of required EBD. Results: ETI was performed in one group of patients (study group, n ⫽ 21) but not in the other (control group, n ⫽ 20). The incidence of stricture was significantly lower in the study group (19.0%) than in the control group (75.0%; P ⬍ .001). The number of required EBDs was also lower in the study group (mean, 1.7; range, 0-15) than in the control group (mean, 6.6; range 0-20). There were no side effects or complications associated with ETI. Limitations: Nonrandomized study design and small number of patients in a single endoscopic center. Conclusions: This study suggests that ETI is safe and effective for the prevention of esophageal stricture in patients undergoing ESD for superficial esophageal squamous cell carcinomas.
Endoscopic submucosal dissection (ESD) is a useful, minimally invasive procedure for management of superficial esophageal carcinomas, allowing en bloc resection of large Abbreviations: EBD, endoscopic balloon dilatation; ESD, endoscopic submucosal dissection; ETI, endoscopic triamcinolone injection. DISCLOSURE: All authors disclosed no financial relationships relevant to this publication. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2011.07.070 Received April 29, 2011. Accepted July 27, 2011. Current affiliations: Department of Endoscopy (1), Division of Gastroenterology (2), Niigata University Medical and Dental Hospital, Niigata, Japan. Reprint requests: Satoru Hashimoto, MD, Department of Endoscopy, Niigata University Medical and Dental Hospital, 1-757 Asahimachi-dori, Chuo-ku, Niigata 951-8510, Japan.
www.giejournal.org
lesions that cannot otherwise be achieved with conventional EMR. Moreover, precise histopathologic assessment can be obtained by detailed examination of the specimens. However, widespread mucosal resection within the narrow esophageal lumen may result in stenotic changes, thus necessitating serial endoscopic balloon dilatation (EBD) procedures over a long period.1 Therefore, the development of strategies to prevent esophageal strictures after ESD would be of benefit. Glucocorticoids inhibit fibrosis by preventing the migration and activation of inflammatory cells and fibroblasts.2 A previous study reported that intralesional injection of triamcinolone augmented the therapeutic effects of balloon dilatation in patients with benign esophageal strictures.3 Therefore, the goal of this study was to determine the utility of endoscopic triamcinolone injection (ETI) for the prevention of stricture formation after ESD. Volume 74, No. 6 : 2011 GASTROINTESTINAL ENDOSCOPY 1389
Endoscopic triamcinolone injection
Hashimoto et al
Take-home Message ●
Endoscopic triamcinolone injection may prevent esophageal stricture after widespread endoscopic submucosal dissection.
a balloon dilator (CRE Fixed Wire Balloon Dilators; Boston Scientific Japan Co., Tokyo, Japan) until the endoscope could be passed through the formerly stenotic area.
Statistical analysis Figure 1. Endoscopic picture shows triamcinolone injection into the cautery ulcer base.
METHODS Patients A total of 336 patients with 380 superficial esophageal squamous cell carcinomas were treated with ESD in our department from February 2003 to July 2010. This study involved 41 consecutive patients with semicircumferential mucosal defects that affected three-fourths of the circumference of the esophagus. Informed consent to participate in this study was obtained from all patients. This study was approved by the Ethics Committee of our institution. The study group comprised 21 patients who underwent ETI (patients treated since January 2008), and the control group comprised 20 patients who did not receive ETI (patients treated before January 2008).
The incidence of stricture and frequency of required EBD was compared between control and study groups. The independent t test was used to compare the age of the patients, the resection size, and the procedure time. The Mann-Whitney U test was used to determine differences in frequency of required EBD. Other categorical data were analyzed by using the chi-square test. P values ⬍ .05 were considered statistically significant.
RESULTS Table 1 summarizes baseline data and treatment outcomes. There was no significant difference in sex, age, tumor location, depth of tumor invasion, resection size, or procedure time when comparing the two groups.
Protocol ETI was performed by using triamcinolone acetonide (10 mg/mL) without further dilution beginning at 3 days after ESD. Premedication for sedation and pain relief was not performed. A 25-gauge, 4-mm needle (TOP Corporation, Tokyo, Japan) was used for injections. A 1-mL syringe was used to inject triamcinolone manually, which facilitated secure injection with consistent pressure. After the needle was inserted shallowly (so as to avoid injuring the muscularis propria), triamcinolone was injected in aliquots of 0.2 mL (2 mg) into the cautery ulcer base (Fig. 1). Injections were performed equally (1 cm apart) in a semicircumferential fashion (Fig. 2). The number of injections per session was dependent on the size of resection and ranged from 9 to 31. The total dose of triamcinolone per session ranged from 18 to 62 mg. Sessions were performed at 3, 7, and 10 days after ESD (total of 3 sessions). Esophagoscopy was performed to assess for stenosis at 1 week, 1 month, 6 months, and 1 year after ETI. Post-ESD stricture was defined when patients complained of dysphagia or when a standard endoscope (GIF-Q240; Olympus Medical Systems, Tokyo, Japan) could not be passed through the ESD scar. EBD was repeated 1 or 2 times per week with 1390 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 6 : 2011
Figure 2. Injections were performed at 1-cm intervals.
www.giejournal.org
Hashimoto et al
Endoscopic triamcinolone injection
TABLE 1. Baseline data and treatment outcomes Study group (n ⴝ 21)
Control group (n ⴝ 20)
P value
19/2
17/3
NS
73.6 (60-89)
68.1 (49-88)
NS
Sex (male/female) Age, mean (range), y Tumor location
NS
Upper thoracic
2
0
Middle thoracic
9
11
Lower thoracic
7
8
Abdominal
3
1
Depth of tumor invasion
NS
Epithelium*
5
3
Lamina propria mucosa†
10
5
Muscularis mucosa‡
4
9
SM1§
0
1
SM2/3㛳
2
2
54.9 (28-67)
62.4 (40-100)
NS
150.5 (90-290)
186.2 (78-240)
NS
19.0% (4/21)
75.0% (15/20)
P⬍.001
1.7 (0-15)
6.6 (0-20)
P⬍.001
Resection size, mean (range), mm ESD procedure time, mean (range), min Proportion of patients developing stricture No. of required EBD, mean (range)
NS, Not significant; SM1, superficial invasion; SM2/3, massive invasion; ESD, endoscopic submucosal dissection; EBD, endoscopic balloon dilatation. *Intraepithelial neoplasia. †Invasion through the basement membrane to the lamina propria. ‡Invasion to the muscularis mucosa. §SM1, superficial invasion (ⱕ200 m below the muscularis mucosa into the submucosa). 㛳SM2/3, massive invasion (⬎200 m into the submucosa).
The proportion of patients developing stricture was significantly lower in the study group (19.0%, 4/21) than in the control group (75.0%, 15/20) (P ⬍ .001). The number of required EBD procedures was significantly lower in the study group (mean 1.7, range 0-15) than in the control group (mean 6.6, range 0-20) (P ⬍ .001). There were no side effects or complications, such as delayed perforation or mediastinal abscess, associated with the injection procedure. A representative case from the study group is illustrated in Figure 3.
DISCUSSION The present study is the first report to demonstrate that ETI resulted in a decreased incidence of stricture and a decreased need for EBD in patients undergoing ESD for superficial esophageal squamous cell carcinomas. Although this study was a retrospective analysis against historical controls, ETI produced a marked effect in terms of prevention of esophageal stricture after ESD. Alternatively, it is possible that these recent cases benefited from www.giejournal.org
ongoing refinements in procedural techniques, which thereby resulted in a lower rate of strictures. However, the procedure time was similar when comparing the ETI group and control group. Although this study suggests the efficacy of ETI, the true benefits and risks of the injection have not yet been validated. A randomized, controlled trial would be warranted for this purpose. Steroids modulate wound healing through their antiinflammatory effects by decreasing prolyl hydroxylase activity and by amplifying collagenase activity, thereby reducing tissue collagen content.4 Although this study used ETI as described in previous reports,2,5,6 the present protocols used ETI before stricture formation. By contrast, previous reports used ETI after fibrotic stricture formation. Because fibroblast proliferation begins at 3 to 7 days after wound injury,7 we used this time point to begin ETI and injected steroids into active ulcerations. The present results suggest that ETI is effective for suppressing inflammatory cell infiltration and fibrosis. A previous study reported that direct injection of triamcinolone (total dose, 80 mg) into exposed esophageal Volume 74, No. 6 : 2011 GASTROINTESTINAL ENDOSCOPY 1391
Endoscopic triamcinolone injection
Hashimoto et al
Figure 3. A, Chromoendoscopy with iodine staining showed an esophageal cancer that occupied the semicircumferential space in the middle thoracic area. B, Mucosal defect after removal of the lesion with endoscopic submucosal dissection. The resection size was 55 mm. C, Endoscopic triamcinolone injection was performed 3 times, and endoscopic imaging on day 18 after endoscopic submucosal dissection showed a mucosal defect with a thin surface coat. D, Endoscopic imaging on day 184 showed complete epithelialization and no stricture.
submucosa tissue of 4 pigs (20 mg injections in 4 quadrants) was subsequently complicated by the development of esophageal abscesses in all cases.8 In the present study, ETIs were performed shallowly at equal spaces in aliquots of 0.2 mL (2 mg), with a total dose of from 18 to 62 mg, and did not result in significant complications, including delayed perforation or mediastinal abscess. Further study would be of benefit to determine the optimal dose for effective and safe action of triamcinolone. The results of this study may apply to semicircumferential as well as completely circumferential mucosal defects. Meanwhile, investigations that use regenerative medicine technology have been conducted. For example, Ohki et al9 demonstrated that endoscopic transplantation of tissue-engineered autologous oral mucosa could enhance wound healing after ESD and possibly prevent esophageal stenosis. Nieponice et al10 reported that endoscopic placement of an extracellular matrix scaffold material prevented esophageal stricture after circumferential EMR. Because those studies were performed in canine models, further investigation is required to determine the efficacy of those strategies in the clinical setting. 1392 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 6 : 2011
In conclusion, this study suggests that ETI is safe and effective for the prevention of esophageal strictures in patients with semicircular mucosal defects due to ESD.
ACKNOWLEDGMENT We thank Tsuneo Oyama (Department of Gastroenterology, Saku General Hospital, Nagano, Japan) for his helpful advice regarding triamcinolone injections.
REFERENCES 1. Katada C, Muto M, Manabe T, et al. Esophageal stenosis after endoscopic mucosal resection of superficial esophageal lesions. Gastrointest Endosc 2003;57:165-9. 2. Miyashita M, Onda M, Okawa K, et al. Endoscopic dexamethasone injection following balloon dilatation of anastomotic stricture after esophagogastrostomy. Am J Surg 1997;174:442-4. 3. Ookawa K, Onda M, Higuchi K, et al. Endoscopic dilatation with steroid injection for anastomotic stricture following esophagectomy. Gastroenterol Endosc 1995;37:2470-5. 4. Carrico TJ, Hehrhof AL, Cohen IK. Biology of wound healing. Surg Clin North Am 1984;64:721-33.
www.giejournal.org
Fiocca et al
Transection of the main bile duct
5. Kochhar R, Makharia GK. Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures. Gastrointest Endosc 2002;56:829-34. 6. Matsuyama T, Aiko S, Yoshizumi Y, et al. A case of esophageal stricture after corrosive esophagitis successfully treated by frequent endoscopic balloon dilation. Esophagus 2004;1:193-7. 7. Werner S, Grose R. Regulation of wound healing by growth factors and cytokines. Physiol Rev 2003;83:835-70. 8. Rajan E, Gostout C, Feitoza A, et al. Widespread endoscopic mucosal
resection of the esophagus with strategies for stricture prevention: a preclinical study. Endoscopy 2005;37:1111-5. 9. Ohki T, Yamato Y, Murakami D, et al. Treatment of oesophageal ulcerations using endoscopic transplantation of tissue-engineered autologous oral mucosal epithelial cell sheets in a canine model. Gut 2006;55:1704-10. 10. Nieponice A, McGrath K, Qureshi I, et al. An extracellular matrix scaffold for esophageal stricture prevention after circumferential EMR. Gastrointest Endosc 2009;69:289-96.
Complete transection of the main bile duct: minimally invasive treatment with an endoscopic-radiologic rendezvous Fausto Fiocca, MD,1 Filippo M. Salvatori, MD,2 Fabrizio Fanelli, MD,2 Antonio Bruni, MD,2 Vincenzo Ceci, MD,1 Mario Corona, MD,2 Gianfranco Donatelli, MD1 Rome, Italy
Background: Complete transection of the common bile duct (CBD) is a dramatic and often extremely difficultto-repair event after surgery. Abdominal biliary fluid collection or jaundice is the initial symptom, and ERCP is the determinant for diagnosis. Objective: To evaluate the safety and efficacy of a combined endoscopic-radiologic technique for the reconstruction of the CBD. Design: Single-center retrospective study. Setting: Tertiary-care center for biliary surgery. Patients: This study involved 22 patients with complete transection of the CBD after cholecystectomy. Intervention: A guidewire is passed in the subhepatic space through the endoscopic approach. A snare loop is advanced from the percutaneous entry site to catch the free end of the wire and then pulled outside the body: a percutaneous biliary-duodenal (PTBD) drainage is put in place. After a new contralateral PTBD, 4 plastic stents are inserted. The stents are removed endoscopically after 8 to 12 months. Main Outcome Measurements: Success of the rendezvous maneuver, patient recovery, and patient mortality. Results: After a mean follow-up period of 4 years, 16 patients are asymptomatic. Two patients are still under treatment, and 4 patients underwent surgery, as was the surgeon’s choice. Limitations: Single-center, retrospective study with a small population. Conclusion: Interruption of the biliary tree does not represent an indication for an often-difficult surgical treatment, because the CBD is often thin in the presence of biliary peritonitis. However, the condition can be treated with a rendezvous technique. Surgery can be performed in elective conditions or completely avoided when conservative therapy is selected.
Complete transection of the common bile duct (CBD) is a serious complication of laparoscopic or open cholecys-
tectomy (incidence range 0%-3.75%; mean 0.31%).1,2 If a bile duct injury is detected during intervention, it should
Abbreviation: CBD, common bile duct.
lar and Interventional Radiology Unit (2), University La Sapienza of Rome, Rome, Italy.
DISCLOSURE: All authors disclosed no financial relationships relevant to this publication. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2011.07.045 Received April 27, 2011. Accepted July 21, 2011. Current affiliations: Department of Surgical Sciences and Organ Transplantation—P. Stefanini (1), Department of Radiological Sciences, Vascu-
www.giejournal.org
Reprint requests: Professor Fausto Fiocca, MD, Department of Surgical Sciences and Organ Transplantation—P. Stefanini, University La Sapienza of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy. If you would like to chat with an author of this article, you may contact Dr Fiocca at [email protected].
Volume 74, No. 6 : 2011 GASTROINTESTINAL ENDOSCOPY 1393
The efficacy of endoscopic triamcinolone injection for the prevention of esophageal stricture after endoscopic submucosal dissection Satoru Hashimoto, MD,1 Masaaki Kobayashi, MD,1 Manabu Takeuchi, MD,2 Yuichi Sato, MD,2 Rintaro Narisawa, MD,1 Yutaka Aoyagi, MD2 Niigata, Japan
Background: Use of endoscopic submucosal dissection (ESD) for management of widespread superficial esophageal carcinomas may be complicated by the development of severe strictures, which may require serial treatment with endoscopic balloon dilatation (EBD). Objective: The goal of this study was to determine the efficacy of endoscopic triamcinolone injection (ETI) for the prevention of stricture formation after ESD. Design: Case series. Setting: Tertiary-care referral center. Patients: A total of 41 consecutive patients who had a semi-circumferential mucosal defect that arose after ESD for superficial esophageal squamous cell carcinomas were enrolled in this study. Interventions: EBD and ETI. Main outcome measurements: Incidence of stricture and frequency of required EBD. Results: ETI was performed in one group of patients (study group, n ⫽ 21) but not in the other (control group, n ⫽ 20). The incidence of stricture was significantly lower in the study group (19.0%) than in the control group (75.0%; P ⬍ .001). The number of required EBDs was also lower in the study group (mean, 1.7; range, 0-15) than in the control group (mean, 6.6; range 0-20). There were no side effects or complications associated with ETI. Limitations: Nonrandomized study design and small number of patients in a single endoscopic center. Conclusions: This study suggests that ETI is safe and effective for the prevention of esophageal stricture in patients undergoing ESD for superficial esophageal squamous cell carcinomas.
Endoscopic submucosal dissection (ESD) is a useful, minimally invasive procedure for management of superficial esophageal carcinomas, allowing en bloc resection of large Abbreviations: EBD, endoscopic balloon dilatation; ESD, endoscopic submucosal dissection; ETI, endoscopic triamcinolone injection. DISCLOSURE: All authors disclosed no financial relationships relevant to this publication. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2011.07.070 Received April 29, 2011. Accepted July 27, 2011. Current affiliations: Department of Endoscopy (1), Division of Gastroenterology (2), Niigata University Medical and Dental Hospital, Niigata, Japan. Reprint requests: Satoru Hashimoto, MD, Department of Endoscopy, Niigata University Medical and Dental Hospital, 1-757 Asahimachi-dori, Chuo-ku, Niigata 951-8510, Japan.
www.giejournal.org
lesions that cannot otherwise be achieved with conventional EMR. Moreover, precise histopathologic assessment can be obtained by detailed examination of the specimens. However, widespread mucosal resection within the narrow esophageal lumen may result in stenotic changes, thus necessitating serial endoscopic balloon dilatation (EBD) procedures over a long period.1 Therefore, the development of strategies to prevent esophageal strictures after ESD would be of benefit. Glucocorticoids inhibit fibrosis by preventing the migration and activation of inflammatory cells and fibroblasts.2 A previous study reported that intralesional injection of triamcinolone augmented the therapeutic effects of balloon dilatation in patients with benign esophageal strictures.3 Therefore, the goal of this study was to determine the utility of endoscopic triamcinolone injection (ETI) for the prevention of stricture formation after ESD. Volume 74, No. 6 : 2011 GASTROINTESTINAL ENDOSCOPY 1389
Endoscopic triamcinolone injection
Hashimoto et al
Take-home Message ●
Endoscopic triamcinolone injection may prevent esophageal stricture after widespread endoscopic submucosal dissection.
a balloon dilator (CRE Fixed Wire Balloon Dilators; Boston Scientific Japan Co., Tokyo, Japan) until the endoscope could be passed through the formerly stenotic area.
Statistical analysis Figure 1. Endoscopic picture shows triamcinolone injection into the cautery ulcer base.
METHODS Patients A total of 336 patients with 380 superficial esophageal squamous cell carcinomas were treated with ESD in our department from February 2003 to July 2010. This study involved 41 consecutive patients with semicircumferential mucosal defects that affected three-fourths of the circumference of the esophagus. Informed consent to participate in this study was obtained from all patients. This study was approved by the Ethics Committee of our institution. The study group comprised 21 patients who underwent ETI (patients treated since January 2008), and the control group comprised 20 patients who did not receive ETI (patients treated before January 2008).
The incidence of stricture and frequency of required EBD was compared between control and study groups. The independent t test was used to compare the age of the patients, the resection size, and the procedure time. The Mann-Whitney U test was used to determine differences in frequency of required EBD. Other categorical data were analyzed by using the chi-square test. P values ⬍ .05 were considered statistically significant.
RESULTS Table 1 summarizes baseline data and treatment outcomes. There was no significant difference in sex, age, tumor location, depth of tumor invasion, resection size, or procedure time when comparing the two groups.
Protocol ETI was performed by using triamcinolone acetonide (10 mg/mL) without further dilution beginning at 3 days after ESD. Premedication for sedation and pain relief was not performed. A 25-gauge, 4-mm needle (TOP Corporation, Tokyo, Japan) was used for injections. A 1-mL syringe was used to inject triamcinolone manually, which facilitated secure injection with consistent pressure. After the needle was inserted shallowly (so as to avoid injuring the muscularis propria), triamcinolone was injected in aliquots of 0.2 mL (2 mg) into the cautery ulcer base (Fig. 1). Injections were performed equally (1 cm apart) in a semicircumferential fashion (Fig. 2). The number of injections per session was dependent on the size of resection and ranged from 9 to 31. The total dose of triamcinolone per session ranged from 18 to 62 mg. Sessions were performed at 3, 7, and 10 days after ESD (total of 3 sessions). Esophagoscopy was performed to assess for stenosis at 1 week, 1 month, 6 months, and 1 year after ETI. Post-ESD stricture was defined when patients complained of dysphagia or when a standard endoscope (GIF-Q240; Olympus Medical Systems, Tokyo, Japan) could not be passed through the ESD scar. EBD was repeated 1 or 2 times per week with 1390 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 6 : 2011
Figure 2. Injections were performed at 1-cm intervals.
www.giejournal.org
Hashimoto et al
Endoscopic triamcinolone injection
TABLE 1. Baseline data and treatment outcomes Study group (n ⴝ 21)
Control group (n ⴝ 20)
P value
19/2
17/3
NS
73.6 (60-89)
68.1 (49-88)
NS
Sex (male/female) Age, mean (range), y Tumor location
NS
Upper thoracic
2
0
Middle thoracic
9
11
Lower thoracic
7
8
Abdominal
3
1
Depth of tumor invasion
NS
Epithelium*
5
3
Lamina propria mucosa†
10
5
Muscularis mucosa‡
4
9
SM1§
0
1
SM2/3㛳
2
2
54.9 (28-67)
62.4 (40-100)
NS
150.5 (90-290)
186.2 (78-240)
NS
19.0% (4/21)
75.0% (15/20)
P⬍.001
1.7 (0-15)
6.6 (0-20)
P⬍.001
Resection size, mean (range), mm ESD procedure time, mean (range), min Proportion of patients developing stricture No. of required EBD, mean (range)
NS, Not significant; SM1, superficial invasion; SM2/3, massive invasion; ESD, endoscopic submucosal dissection; EBD, endoscopic balloon dilatation. *Intraepithelial neoplasia. †Invasion through the basement membrane to the lamina propria. ‡Invasion to the muscularis mucosa. §SM1, superficial invasion (ⱕ200 m below the muscularis mucosa into the submucosa). 㛳SM2/3, massive invasion (⬎200 m into the submucosa).
The proportion of patients developing stricture was significantly lower in the study group (19.0%, 4/21) than in the control group (75.0%, 15/20) (P ⬍ .001). The number of required EBD procedures was significantly lower in the study group (mean 1.7, range 0-15) than in the control group (mean 6.6, range 0-20) (P ⬍ .001). There were no side effects or complications, such as delayed perforation or mediastinal abscess, associated with the injection procedure. A representative case from the study group is illustrated in Figure 3.
DISCUSSION The present study is the first report to demonstrate that ETI resulted in a decreased incidence of stricture and a decreased need for EBD in patients undergoing ESD for superficial esophageal squamous cell carcinomas. Although this study was a retrospective analysis against historical controls, ETI produced a marked effect in terms of prevention of esophageal stricture after ESD. Alternatively, it is possible that these recent cases benefited from www.giejournal.org
ongoing refinements in procedural techniques, which thereby resulted in a lower rate of strictures. However, the procedure time was similar when comparing the ETI group and control group. Although this study suggests the efficacy of ETI, the true benefits and risks of the injection have not yet been validated. A randomized, controlled trial would be warranted for this purpose. Steroids modulate wound healing through their antiinflammatory effects by decreasing prolyl hydroxylase activity and by amplifying collagenase activity, thereby reducing tissue collagen content.4 Although this study used ETI as described in previous reports,2,5,6 the present protocols used ETI before stricture formation. By contrast, previous reports used ETI after fibrotic stricture formation. Because fibroblast proliferation begins at 3 to 7 days after wound injury,7 we used this time point to begin ETI and injected steroids into active ulcerations. The present results suggest that ETI is effective for suppressing inflammatory cell infiltration and fibrosis. A previous study reported that direct injection of triamcinolone (total dose, 80 mg) into exposed esophageal Volume 74, No. 6 : 2011 GASTROINTESTINAL ENDOSCOPY 1391
Endoscopic triamcinolone injection
Hashimoto et al
Figure 3. A, Chromoendoscopy with iodine staining showed an esophageal cancer that occupied the semicircumferential space in the middle thoracic area. B, Mucosal defect after removal of the lesion with endoscopic submucosal dissection. The resection size was 55 mm. C, Endoscopic triamcinolone injection was performed 3 times, and endoscopic imaging on day 18 after endoscopic submucosal dissection showed a mucosal defect with a thin surface coat. D, Endoscopic imaging on day 184 showed complete epithelialization and no stricture.
submucosa tissue of 4 pigs (20 mg injections in 4 quadrants) was subsequently complicated by the development of esophageal abscesses in all cases.8 In the present study, ETIs were performed shallowly at equal spaces in aliquots of 0.2 mL (2 mg), with a total dose of from 18 to 62 mg, and did not result in significant complications, including delayed perforation or mediastinal abscess. Further study would be of benefit to determine the optimal dose for effective and safe action of triamcinolone. The results of this study may apply to semicircumferential as well as completely circumferential mucosal defects. Meanwhile, investigations that use regenerative medicine technology have been conducted. For example, Ohki et al9 demonstrated that endoscopic transplantation of tissue-engineered autologous oral mucosa could enhance wound healing after ESD and possibly prevent esophageal stenosis. Nieponice et al10 reported that endoscopic placement of an extracellular matrix scaffold material prevented esophageal stricture after circumferential EMR. Because those studies were performed in canine models, further investigation is required to determine the efficacy of those strategies in the clinical setting. 1392 GASTROINTESTINAL ENDOSCOPY Volume 74, No. 6 : 2011
In conclusion, this study suggests that ETI is safe and effective for the prevention of esophageal strictures in patients with semicircular mucosal defects due to ESD.
ACKNOWLEDGMENT We thank Tsuneo Oyama (Department of Gastroenterology, Saku General Hospital, Nagano, Japan) for his helpful advice regarding triamcinolone injections.
REFERENCES 1. Katada C, Muto M, Manabe T, et al. Esophageal stenosis after endoscopic mucosal resection of superficial esophageal lesions. Gastrointest Endosc 2003;57:165-9. 2. Miyashita M, Onda M, Okawa K, et al. Endoscopic dexamethasone injection following balloon dilatation of anastomotic stricture after esophagogastrostomy. Am J Surg 1997;174:442-4. 3. Ookawa K, Onda M, Higuchi K, et al. Endoscopic dilatation with steroid injection for anastomotic stricture following esophagectomy. Gastroenterol Endosc 1995;37:2470-5. 4. Carrico TJ, Hehrhof AL, Cohen IK. Biology of wound healing. Surg Clin North Am 1984;64:721-33.
www.giejournal.org
Fiocca et al
Transection of the main bile duct
5. Kochhar R, Makharia GK. Usefulness of intralesional triamcinolone in treatment of benign esophageal strictures. Gastrointest Endosc 2002;56:829-34. 6. Matsuyama T, Aiko S, Yoshizumi Y, et al. A case of esophageal stricture after corrosive esophagitis successfully treated by frequent endoscopic balloon dilation. Esophagus 2004;1:193-7. 7. Werner S, Grose R. Regulation of wound healing by growth factors and cytokines. Physiol Rev 2003;83:835-70. 8. Rajan E, Gostout C, Feitoza A, et al. Widespread endoscopic mucosal
resection of the esophagus with strategies for stricture prevention: a preclinical study. Endoscopy 2005;37:1111-5. 9. Ohki T, Yamato Y, Murakami D, et al. Treatment of oesophageal ulcerations using endoscopic transplantation of tissue-engineered autologous oral mucosal epithelial cell sheets in a canine model. Gut 2006;55:1704-10. 10. Nieponice A, McGrath K, Qureshi I, et al. An extracellular matrix scaffold for esophageal stricture prevention after circumferential EMR. Gastrointest Endosc 2009;69:289-96.
Complete transection of the main bile duct: minimally invasive treatment with an endoscopic-radiologic rendezvous Fausto Fiocca, MD,1 Filippo M. Salvatori, MD,2 Fabrizio Fanelli, MD,2 Antonio Bruni, MD,2 Vincenzo Ceci, MD,1 Mario Corona, MD,2 Gianfranco Donatelli, MD1 Rome, Italy
Background: Complete transection of the common bile duct (CBD) is a dramatic and often extremely difficultto-repair event after surgery. Abdominal biliary fluid collection or jaundice is the initial symptom, and ERCP is the determinant for diagnosis. Objective: To evaluate the safety and efficacy of a combined endoscopic-radiologic technique for the reconstruction of the CBD. Design: Single-center retrospective study. Setting: Tertiary-care center for biliary surgery. Patients: This study involved 22 patients with complete transection of the CBD after cholecystectomy. Intervention: A guidewire is passed in the subhepatic space through the endoscopic approach. A snare loop is advanced from the percutaneous entry site to catch the free end of the wire and then pulled outside the body: a percutaneous biliary-duodenal (PTBD) drainage is put in place. After a new contralateral PTBD, 4 plastic stents are inserted. The stents are removed endoscopically after 8 to 12 months. Main Outcome Measurements: Success of the rendezvous maneuver, patient recovery, and patient mortality. Results: After a mean follow-up period of 4 years, 16 patients are asymptomatic. Two patients are still under treatment, and 4 patients underwent surgery, as was the surgeon’s choice. Limitations: Single-center, retrospective study with a small population. Conclusion: Interruption of the biliary tree does not represent an indication for an often-difficult surgical treatment, because the CBD is often thin in the presence of biliary peritonitis. However, the condition can be treated with a rendezvous technique. Surgery can be performed in elective conditions or completely avoided when conservative therapy is selected.
Complete transection of the common bile duct (CBD) is a serious complication of laparoscopic or open cholecys-
tectomy (incidence range 0%-3.75%; mean 0.31%).1,2 If a bile duct injury is detected during intervention, it should
Abbreviation: CBD, common bile duct.
lar and Interventional Radiology Unit (2), University La Sapienza of Rome, Rome, Italy.
DISCLOSURE: All authors disclosed no financial relationships relevant to this publication. Copyright © 2011 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 doi:10.1016/j.gie.2011.07.045 Received April 27, 2011. Accepted July 21, 2011. Current affiliations: Department of Surgical Sciences and Organ Transplantation—P. Stefanini (1), Department of Radiological Sciences, Vascu-
www.giejournal.org
Reprint requests: Professor Fausto Fiocca, MD, Department of Surgical Sciences and Organ Transplantation—P. Stefanini, University La Sapienza of Rome, Policlinico Umberto I, Viale del Policlinico 155, 00161 Rome, Italy. If you would like to chat with an author of this article, you may contact Dr Fiocca at [email protected].
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