Evaluation of safety and efficacy of autologous oral mucosa-derived epithelial cell sheet transplantation for prevention of anastomotic restenosis in congenital esophageal atresia and congenital esophageal stenosis

Abstract

Background: We performed the first autologous oral mucosa-derived epithelial cell sheet transplantation therapy in a patient with refractory postoperative anastomotic stricture in congenital esophageal atresia (CEA) and confirmed its safety. In this study, patients with CEA and congenital esophageal stenosis were newly added as subjects to further evaluate the safety and efficacy of cell sheet transplantation therapy.

Methods: Epithelial cell sheets were prepared from the oral mucosa of the subjects and transplanted into esophageal tears created by endoscopic balloon dilatation (EBD). The safety of the cell sheets was confirmed by quality control testing, and the safety of the transplantation treatment was confirmed by 48-week follow-up examinations.

Results: Subject 1 had a stenosis resected because the frequency of EBD did not decrease after the second transplantation. Histopathological examination of the resected stenosis revealed marked thickening of the submucosal layer. Subjects 2 and 3 did not require EBD for 48 weeks after transplantation, during which time they were able to maintain a normal diet by mouth.

Conclusions: Subjects 2 and 3 were free of EBD for a long period of time after transplantation, confirming that cell sheet transplantation therapy is clearly effective in some cases. In the future, it is necessary to study more cases; develop new technologies such as an objective index to evaluate the efficacy of cell sheet transplantation therapy and a device to achieve more accurate transplantation; identify cases in which the current therapy is effective; and find the optimal timing of transplantation; and clarify the mechanism by which the current therapy improves stenosis.

Trial registration: UMIN, UMIN000034566, registered 19 October 2018, https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000039393 .

Keywords: Anastomotic stenosis; Cell sheet transplantation; Congenital esophageal atresia; Congenital esophageal stenosis; Endoscopy; Epithelial cell sheet; Regenerative therapy; Somatic stem cells.

Fig. 1

Second epithelial cell sheet transplantation in subject 1. A Endoscopic image of the transplanted area approximately 3 weeks (23 days) after the first epithelial cell sheet transplantation. The first EBD after transplantation was performed on the same day. B Contrast esophagography during EBD. Arrows indicate the stenotic area. The balloon was filled with contrast at 1 atm of internal pressure. C Enlarged image of the esophageal stenosis. The dotted line on the left side is approximately 34.6 mm, and the right side is 20.8 mm. D Endoscopic image immediately after the second cell sheet transplantation. The cell sheet was transplanted in the mucosal defect area indicated by the dotted line. E Macroscopic view of the resected postoperative anastomotic stenosis of esophageal atresia (right: mouth side, left: stomach side). F Histology of the stenotic region surrounded by the white line in Fig. 1E. The submucosal layer was thickened with fibrotic tissue (HE staining, upper panel). In the area between the dotted lines, a lack of continuity of the muscle layer was observed (desmin staining, middle panel). In the area enclosed by the dotted line, an accumulation of myofibroblasts was observed in the submucosa of the smooth muscle defect (α-SMA staining, lower panel). Scale bar is 2 mm

Fig. 2

Epithelial cell sheet transplantation into subject 2. A Endoscopic image of the stenosis just before EBD at cell sheet transplantation. B Contrast esophagography during EBD just before cell sheet transplantation. Arrows indicate the stenosis. The balloon was filled with contrast at 1 atm of internal pressure. C Enlarged image of the esophageal stenosis. The dotted line on the left is approximately 15.1 mm, and the right is 11.5 mm. D Endoscopic image after EBD just before cell sheet transplantation. Arrows indicate the location of the laceration caused by EBD. E The cell sheets were applied to the mucosa dehiscence above the laceration using the transplantation device. F Contrast esophagography before EBD at cell sheet transplantation. Arrows indicate anastomotic stenosis. G Contrast esophagography approximately one month (39 days) after cell sheet transplantation. Arrows indicate the stenosis. H Contrast esophagography approximately 5 months (154 days) after cell sheet transplantation. Arrows indicate the stenosis. I Endoscopic image of the stenosis approximately 5 months (154 days) after cell sheet transplantation. Arrows indicate the location of the laceration caused by EBD immediately before transplantation. J Endoscopic image of the stenosis approximately 12 months (348 days) after cell sheet transplantation. Arrows indicate the location of the laceration caused by EBD immediately before transplantation

Fig. 3

Epithelial cell sheet transplantation into subject 3. A Endoscopic image of the stenosis just before EBD at cell sheet transplantation. B Contrast esophagography during balloon dilation just before cell sheet transplantation. Arrows indicate the stenosis. The balloon was filled with contrast at 1 atm of internal pressure. C Enlarged image of the esophageal stenosis. The dotted line on the left is approximately 22.7 mm and the right is 21.8 mm. D Endoscopic image after balloon dilation just before cell sheet implantation. Arrows indicate the location of the laceration caused by balloon dilation. E The cell sheets were attached to the mucous dehiscence above the laceration using the transplantation device. F Contrast esophagography approximately one month before cell sheet transplantation. Arrows indicate anastomotic stenosis. G Contrast esophagography approximately 3 months (91 days) after cell sheet transplantation. Arrows indicate stenosis. H Contrast esophagography approximately five and a half months (166 days) after cell sheet transplantation. Arrows indicate the stenosis. I Endoscopic image of the stenosis approximately one month (28 days) after cell sheet transplantation. Arrows indicate the location of the laceration caused by balloon dilation just before transplantation

Fig. 4

Endoscopic balloon dilatation before and after cell sheet transplantation in each case. The time axis shows the status of EBD before and after cell sheet transplantation in subjects 1–3. Blue triangles indicate EBD, red arrows indicate cell sheet transplantation, and a black arrow indicates resection of the stenosis. The distance between triangles and arrows indicates the interval between procedures