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Biodegradable esophageal stent placement does not prevent high-grade stricture formation after circumferential mucosal resection in a porcine model

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Abstract

Background

Advanced esophageal dysplasia and early cancers have been treated traditionally with esophagectomy. Endoscopic esophageal mucosectomy (EEM) offers less-invasive therapy, but high-degree stricture formation limits its applicability. We hypothesized that placement of a biodegradable stent (BD-stent) immediately after circumferential EEM would prevent stricturing.

Methods

Ten pigs (five unstented controls, five BD-stent) were utilized. Under anesthesia, a flexible endoscope with a band ligator and snare was used to incise the mucosa approximately 20 cm proximal to the lower esophageal sphincter. A 10-cm, circumferential, mucosal segment was dissected and excised by using snare electrocautery. In the stented group, an 18-×120-mm, self-expanding, woven polydioxanone stent (ELLA-CS, Hradec-Kralove) was deployed. Weekly esophagograms evaluated for percent reduction in esophageal diameter, stricture length, and proximal esophageal dilation. Animals were euthanized when the stricture exceeded 80 % and were unable to gain weight (despite high-calorie liquid diet) or at 14 weeks.

Results

The control group rapidly developed esophageal strictures; no animal survived beyond the third week of evaluation. At 2 weeks post-EEM, the BD-stent group had a significant reduction in esophageal diameter (77.7 vs. 26.6 %, p < 0.001) and degree of proximal dilation (175 vs. 131 %, p = 0.04) compared with controls. Survival in the BD-stent group was significantly longer than in the control group (9.2 vs. 2.4 weeks, p = 0.01). However, all BD-stent animals ultimately developed clinically significant strictures (range, 4–14 weeks). Comparison between the maximum reduction in esophageal diameter and stricture length (immediately before euthanasia) demonstrated no differences between the groups.

Conclusions

Circumferential EEM results in severe stricture formation and clinical deterioration within 3 weeks. BD-stent placement significantly delays the time of clinical deterioration from 2.4 to 9.2 weeks, but does not affect the maximum reduction in esophageal diameter or proximal esophageal dilatation. The timing of stricture formation in the BD-stent group correlated with the loss radial force and stent disintegration.

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Acknowledgments

The stents used in this study were graciously provided by ELLA-CS, Hradec-Kralove, Czech Republic.

Disclosures

Jeffrey M. Marks receives an honorarium as a consultant for Covidien, Olympus, Boston Scientific, WL Gore, and Ethicon and for serving on the advisory board for Apollo Endosurgery. Jeffrey L. Ponsky serves as a consultant for US Endoscopy. None of the other authors have relationships to disclose.

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Authors and Affiliations

  1. Department of Surgery, University Hospitals Case Medical Center, 11100 Euclid Ave, Mail Stop LKS 5047, Cleveland, OH, 44106, USA

    Eric M. Pauli, Steve J. Schomisch, Joseph P. Furlan, Andrea S. Marks, Jeffrey L. Ponsky & Jeffrey M. Marks

  2. Division of Gastroenterology, University Hospitals Case Medical Center, Cleveland, OH, 44106, USA

    Amitabh Chak

  3. Miraca Life Sciences Research Institute, Irving, TX, 75039, USA

    Richard H. Lash

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  1. Eric M. Pauli
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Correspondence to Eric M. Pauli.

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Pauli, E.M., Schomisch, S.J., Furlan, J.P. et al. Biodegradable esophageal stent placement does not prevent high-grade stricture formation after circumferential mucosal resection in a porcine model. Surg Endosc 26, 3500–3508 (2012). https://doi.org/10.1007/s00464-012-2373-6

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  • DOI: https://doi.org/10.1007/s00464-012-2373-6

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