Topical hemostatic powder promotes reepithelialization and reduces scar formation after extensive esophageal mucosal resection

Abstract

The development of techniques for endoscopic resection has provided new strategies for radical conservative treatment of superficial esophageal neoplasms, even those that are circumferential, such as Barrett's neoplasia. However, it is necessary to prevent the formation of scar tissue that can be responsible for esophageal strictures following circumferential resection. Preliminary data have suggested the possible efficacy of a hemostatic powder in the promotion of wound healing. The study aims to assess the effectiveness of Hemospray (Cook Medical) in a swine model of post-endoscopic esophageal stricture. Our prospective controlled study included 21 pigs. A 6-cm circumferential submucosal dissection of the esophagus (CESD) was performed in each pig. Group 1 (n = 11) only underwent CESD and Group 2 (n = 10) had repeated Hemospray applications after CESD. Clinical, endoscopic, and radiological monitoring were performed, blood levels of four inflammatory or pro-fibrotic cytokines were assessed, and histological analysis was performed. Median esophageal diameter was greater in the group treated with Hemospray (2 mm [1-3] vs. 3 mm [2-4], P = 0.01), and the rate of symptomatic esophageal stricture was 100% and 60% in Groups 1 and 2, respectively (P = 0.09). The thicknesses of esophageal fibrosis and inflammatory cell infiltrate were significantly lower in Group 2 than in Group 1 (P = 0.002 and 0.0003, respectively). The length of the neoepithelium was greater in Group 2 than in Group 1 (P = 0.0004). Transforming growth factor-β levels were significantly lower in Group 2 than in Group 1 (P = 0.01). The application of Hemospray after esophageal CESD reduces scar tissue formation and promotes reepithelialization, and therefore is a promising therapeutic approach in the prevention of post-endoscopic esophageal stricture.

Deployment of carboxymethyl cellulose sheets to prevent esophageal stricture after full circumferential endoscopic submucosal dissection: A porcine model

“…In our study, however, quantitative measurements of serum pro‐inflammatory and profibrotic cytokines suggested that the application of CMC sheets on the mucosal defect had an antifibrotic action by downregulating the expression of TGF‐β1. This result was also similar to the effectiveness of hemostatic powder used in wound covering post‐ESD . Thus, we suppose that the different tissue‐shielding methods mentioned above which could reduce fibrosis may have the same result in downregulating serum TGF‐β1 levels because of biomaterial shielding.…”

“…This result was also similar to the effectiveness of hemostatic powder used in wound covering post-ESD. 26 Thus, we suppose that the different tissue-shielding methods mentioned above which could reduce fibrosis may have the same result in downregulating serum TGF-b1 levels because of biomaterial shielding. Further tests are needed to prove this hypothesis.…”

Local Thymosin β4 Gel Injection Prevents Esophageal Stricture after Circumferential Endoscopic Submucosal Dissection in a Porcine Model

“…Mucosal transplantation to the ESD wound is an effective and safe measure, but the technique remains underdeveloped and has cost implications [11]. Other preventive options for stricture mainly referring to local treatments of topical hemostatic powder and poly eth- anol acid membrane still lack sound evidence [12][13][14]. Furthermore, the interventions mentioned above have limited efficacy for the prevention of esophageal stricture after ESD.…”

Non-radical, stepwise complete endoscopic resection of Barrett’s epithelium in short segment Barrett’s esophagus has a low stricture rate

“…To prevent stricture formation after extensive endoscopic resection, the use of oral steroids, the endoscopic injection of steroids or topical application of hemostatic powder or polyglycolic acid sheets have recently been suggested 28 29 30 31 32. Although these techniques seem to be promising, none of the available preventive methods is efficient and safe enough to justify recommendation for routine use in clinical practice 33.…”