Biodegradable esophageal stent placement does not prevent high-grade stricture formation after circumferential mucosal resection in a porcine model.
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.
Department of Surgery, University Hospitals Case Medical Center, 11100 Euclid Ave, Mail Stop LKS 5047, Cleveland, OH 44106, USA. Eric.Pauli@uhhospitals.org
Eric M
EM
Pauli
Steve J
SJ
Schomisch
Joseph P
JP
Furlan
Andrea S
AS
Marks
Amitabh
A
Chak
Richard H
RH
Lash
Jeffrey L
JL
Ponsky
Jeffrey M
JM
Marks
D020341:Absorbable Implants; D000818:Animals; D004940:Esophageal Stenosis / Q000209:etiology* / Q000517:prevention & control*; D016629:Esophagectomy / Q000009:adverse effects*; D004947:Esophagus / Q000601:surgery*; D023421:Models, Animal; D009092:Mucous Membrane / Q000601:surgery; D011474:Prosthesis Design; D015607:Stents; D013552:Swine