New hope for esophageal stricture prevention: A prospective single-center trial on acellular dermal matrix

Abstract

Background: Given the high incidence of esophageal cancer in China, an increasing number of patients there are undergoing endoscopic mucosal dissection (ESD). Although the 5-year survival rate after ESD can exceed 95%, esophageal stricture, the most common and serious postoperative complication, affects the long-term prognosis of patients and the quality of life. Autologous mucosal grafts have proven to be successful in preventing stricture after ESD for early esophageal cancer.

Aim: To examine the viability of acellular dermal matrix (ADM) as an alternative to autologous mucosa for the prevention of stricture after ESD.

Methods: This is a prospective, single-center, controlled study. Consecutive patients who underwent ESD surgery and were willing to undergo autologous mucosal transplantation were recruited between January 1 and December 31, 2017. Consecutive patients who underwent ESD surgery and were willing to undergo ADM transplantation were recruited between January 1 to December 31, 2019. A final three-year follow-up of patients who received transplants was conducted.

Results: Based on the current incidence of esophageal stricture, the sample size required for both the autologous mucosal graft group and the ADM group was calculated to be 160 cases. Due to various factors, a total of 20 patients with autologous mucosal grafts and 25 with ADM grafts were recruited. Based on the inclusion exclusion and withdrawal criteria, 9 patients ultimately received autologous mucosal grafts and completed the follow-up, while 11 patients received ADM grafts and completed the follow-up. Finally, there were 2 cases of stenosis in the autologous mucosal transplantation group with a stenosis rate of 22.22% and 2 cases of stenosis in the ADM transplantation group with a stenosis rate of 18.18%, with no significant difference noted between the groups (P = 0.94).

Conclusion: In this prospective, single-center, controlled trial, we compared the effectiveness of autologous mucosa transplantation and ADM for the prevention of esophageal stricture. Due to certain condition limitations, we were unable to recruit sufficient subjects meeting our target requirements. However, we implemented strict inclusion, exclusion, and withdrawal criteria and successfully completed three years of follow-up, resulting in valuable clinical insights. Based on our findings, we hypothesize that ADM may be similarly effective to autologous mucosal transplantation in the prevention of esophageal stricture, offering a comparable and alternative approach. This study provides a new therapeutic idea and direction for the prevention of esophageal stricture.

Keywords: Duodenal subepithelial lesion; Endoscopic resection; Over-the-scope clip; Perforation.

Figure 1

Operation process of 5/6 periesophageal endoscopic mucosal dissection resection combined with autologous esophageal mucosal transplantation and esophageal covered stent implantation. A: Lugol fluid was sprayed on the whole esophageal mucosa; B: Endoscopic mucosal dissection was performed, and the wound after resection showed an annular mucosal defect; C: The cancerous tissue was removed; D: At the selected normal esophageal mucosa, the mucosa to be transplanted was removed by endoscopic mucosal resection using a polycyclic mucosal resection device; E: A titanium clip was used to secure the excised normal mucosa to the endoscopically peeled mucosal wound; F: The esophageal covered stent was implanted into the compressed transplanted mucosa.

Figure 2

Flow chart of patient inclusion.