Ultrasoic endoscopy guiding to cut scar of esophageal stricture after variceal sclerotherapy

doi:10.21203/rs.3.rs-1415426/v1

PDF

Research Article

Ultrasoic endoscopy guiding to cut scar of esophageal stricture after variceal sclerotherapy

https://doi.org/10.21203/rs.3.rs-1415426/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Objective: We want to investigate the efficacy of ultrasoic endoscopy guiding to cut scar of esophageal stricture after variceal sclerotherapy.

Method: The data of 10 patients with esophageal stricture after esophageal varices sclerotherapy injection(ESI) in our hospital from September 1, 2021 to December 31, 2021 treated by cutting the scar guided by ultrasoic endoscopy were retrospective, and the efficacy was evaluated.

Result: The dysphagia was obviously relieved in 9 patients during follow-up, and 1 patient suffered dysphagia again after the treatment.

There was no complications of perforation, bleeding and infection among the paitents.

Conclusion: Ultrasoic endoscopy guiding to cut scar was safe and reliable, which could reduce the occurrence of perforation and bleeding.

Esophageal stricture is one of the complication after ESI.^[1] It is related to local inflammation, ulceration, and fibrosis caused by multiple EIS.^[2–3] The main symptom of esophageal stricture is dysphagia. The standard treatment for esophageal stricture after ESI is not mentioned in international guidelines.^[4] Further more, patients are often accompanied by prolonged prothrombin time and thrombocytopenia, and balloon dilation for stricture complicated by ESI for esophageal varices has poor outcomes.^[1]

Object

We reviewed the data of 10 patients with esophageal stricture after ESI in our hospital from September 1, 2021 to December 31, 2021 treated by cutting the scar guided by ultrasoic endoscopy.

Inclusion criteria

① According to Stooler classification ^[5], the degree of esophageal stricture was grade II-VI. ② Diameter of esophageal cavity was more than 2.6mm, where ultrasoic endoscope could pass. ③ The esophageal stricture did not be treat with surgery.

Exclusion criteria

① Disorder of coagulation was severe. ② The signs of vital were unstable. ③ Heart, brain, lung, or other organ was failure. ④ Esophageal malignancy was found.

Assessment

The degree of esophageal stricture and dysphagia^[5]: Grade 0: There is no dietary restriction; Grade I: Soft food can be eaten smoothly, and the food whose diameter is more than 13 mm can be passed; Grade II: Semi-liquid food whose diameter is among 8 to 13 mm can be passed; Grade III: Only liquid diet whose diameter is among 3 to 8 mm; Grade IV: Liquid diet was difficult to be passed, whose diameter is less than 3 mm.

The relief criteria of esophageal stricture: ① The degree of stricture recover to grade 0-I. ② The body of standard gastroscope can pass through esophagus without any resistance, and the diameter gastroscope is 1 cm. ③ There will be no stricture recurred during the follow-up 8 weeks. ^[6]

Criteria of stricture recurred: ① The degree of stricture worsen to grade II-IV again. ② The body of standard gastroscope can not pass through esophagus without any resistance.

Endoscopic treatment

At first, We should observe the retention in the esophageal cavity through gastroscopy. If amount of fluid and/or solid was blocked by the stricture, it was necessary to remove the residue. When the esophageal stricture exposed entirely (Figure.1), we used the microprobe of ultrasoic endoscope to scan the esophageal stricture.(Figure.2) After measuring the location and depth of stricture scar, we used the dualknife to cut the scar by longitudinal axis according to measurement.(Figure.3) However, we should be alert to slit the longitudinal muscle of the esophagus.

General data: Gender: There were 7 males and 3 females; Age: The average age was 47 years, ranging from 35 to 59 years; Reason of cirrhosis: There were 9 cases of hepatitis B, and 1 case of alcoholic cirrhosis; Child-Plug classification: There were 4 cases of grade A, 4 cases of grade B, and 2 cases of grade C. Portal thrombosis: There were 3 cases combined portal thrombosis. Hepatocellular carcinoma(HCC): There were both 2 cases combined with HCC. Splenectomy: There were

3 cases treated with Splenectomy. Antiviral: There were 7 cases treated with antiviral; Time of ESI: There were among 1 to 6 times of ESI fefore. Time of dilation: There were among 0 to 4 times of dilation for stricture before. Thick of scar: The thick of stricture scar was 1.1 to 3.9mm. Location of scar: Distances to incisor of the scar was among 34 cm to 39 cm, and derections of scar were at one o'clock, two o'clock, nine o'clock, ten o'clock, eleven o'clock, twelve o'clock. Degree of stricture: There were 3 cases with grade II, 5 cases with grade III, 2 cases with grade IV. (Table. 1)

Efficacy: The dysphagia was obviously relieved in 9 patients during follow-up among three months to six months. 1 patient suffered dysphagia again within one month after the treatment, and endoscope found that the degree of stricture was grade III. There was no complication of perforation, bleeding and infection among the paitents.

Esophageal stricture is one of the complications after ESI, and the incidence of stricture is among 2% and 10% ^[7]. However, it seriously affects the quality of life to the patient. The reasons of esophageal stricture after ESI are as follow ^{[1, 2, 8]}:①Vascular endothelial is injured, chronic inflammation and fibrous scars gradually formed after the sclerosant injected into varices.②Barrier of esophageal mucosa is damaged. ③The muscularis mucosa and propria of esophagus may injure, which would deriectly lead to scar stricture. ④The injection is near the physiological stricture of the esophagus. ⑤The dose of sclerosant is large. ⑥ The sclerosant is intensively injected at the same level of the esophagus, then amount of fibrous scars are formed on the same circumference of the esophagus. ⑦ Repeatedly injections of sclerosant induce the scar tissue overlaped, and interlaced.

The endoscopic treatment for benign esophageal stricture includs balloon dilation, local incision, and stent placement. Balloon dilatation mainly achieves the effect by the mechanical tension of the balloon, on the other side, it will tear the normal mucosa and/or muscularis around esophagus^[9]. Local incision esophageal stricture is reliable^[10–11], which will significantly relieve the dysphagia in patients. However, there should be alert to the complication of perforation, when the muscularis propria of esophagus are cut. Stent placement will extend the esophageal stricture, however, complications are much more, such as chest pain, reflux esophagitis, displacement or detachment, and tissue embedded stents ^[12–13].

Ultrasoic endoscopy can clearly show the five layers of the normal esophagus. ^[14] When the scar of esophageal inflammatory stricture was detected through ultrasoic endoscopy, it showed that the tissue of scar was more thicker than normal mucosa, and the location and depth of scar could be measured exactly. ^[15]

The particularity of esophageal stricture after ESI for esophageal varices is that most patients are accompanied by risk factors such as residual varices, coagulation dysfunction, low immunity^[16]. The data of 10 patients with esophageal stricture after ESI in our hospital treated by cutting the scar through ultrasoic endoscopy were retrospective in this article.The dysphagia of stricture were obviously relieved in 9 patients during follow-up among three months to six months, and 1 patient suffered dysphagia again within one month after the treatment. There was no complication of perforation, bleeding and infection among the paitents.The advantage of ultrasoic endoscopy guiding to cut scar were as follow: ① It kept away from residual varices, which avoided the bleeding from varices. ② The scar were cut according the depth measured by ultrasoic endoscopy, which would reduce the complication of perforation. ③ The normal mucosa would not be tear as balloon dilatation.

Ultrasoic endoscopy guiding to cut scar was safe and reliable ,which could reduce the occurrence of perforation and bleeding. This study has several limitations mainly related to its retrospective design. More cases and much more longer follow-up time are needed to evaluate the efficacy of ultrasoic endoscopy guiding to cut scar in the treatment of esophageal stricture complicated by ESI.

ESI: esophageal varices sclerotherapy injection;

HCC: hepatocellular carcinoma;

HEB: hepatitis B;

ALC: alcohol;

Ethics approval and consent to participate

The study protocol conformed to the ethical guidelines of the Declaration of Helsinki and was approved by the ethics review committee of HangZhou XiXi Hospital. Written informed consent was obtained from the patient and from all individual participants included in the study. Neither the transplant donor nor the recipient was from a vulnerable population.

Consent for publication

Written informed consent was obtained from the patient for publication of these cases and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.

Availability of data and materials

All data generated or analysed during this study are included in this published article [and its supplementary information files].

Competing interests

The authors declare that they have no competing interests.

Funding

The authors have no source of support or funding to report.

Authors’ contributions

YD Z conceptualized and designed the study.

JX, YS, BW, HW and CJ H performed the data collection.FL Z analyzed and interpreted the data.FL Z and JX drafted and critically revised the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We thank Mr Fu-Long Zhang for his contribution to the data collection and manuscript editing.

Li Jun, Yang Liu, Xie Qiao, et al. A case of severe esophageal stricture after multiple endoscopic sclerotherapy [J] Chinese Journal of Endoscopy, 2018.24(9):101-105.
Wang Pengbin, Li Lixin, Xue Diqiang, et al. The relationship between endoscopic treatment and causes of gastric fundus veins and complicated esophageal stenosis [J]. Gansu Science and Technology, 2018,34 (1): 117-119.
Xue Diqiang, He Xiaoxia, Zhang Yuling, et al. Treatment of two cases of cardiac stenosis caused by endoscopic embolization of esophageal and gastric varicose veins and literature review [J]. Chinese Electronic Journal of Gastrointestinal Endoscopy, 2016,3 (2): 41-44.
Sami SS, Haboubi HN,Ang Y，et al.UK guidelines on oesophageal dilatation in clinical practice[J]. Gut,2018.67(6):1000-1023.
Li Hongke, Su Yongjuan, Han Yide. Clinical effect of removable esophageal stent implantation and balloon dilation in the treatment of refractory esophageal stenosis [J]. Clinical Medicine, 2019, 3:88-93.
Digestive Endoscopy Tunnel Technology Collaboration Group of Digestive Endoscopy Branch of Chinese Medical Association, Endoscopy Branch of Chinese Medical Doctor Association, Digestive Endoscopy Branch of Beijing Medical Association. Expert consensus on endoscopic prevention and treatment of benign and malignant esophageal strictures in China (2020, Beijing) [J] Chinese Journal of Digestive Endoscopy, 2021, 38(3): 173-185.
MUDAWI H M, IBRAHIM K B. Endoscopic variceal sclerotherapy in patiencts with Symmers periportal fibroses[J]. Tropical Doctor, 2007, 37(3):179-181.
Linghu Enqiang. Endoscopic diagnosis and treatment of patients with upper gastrointestinal bleeding caused by esophagogastric varices[J]. Chinese Journal of Digestive Diseases and Imaging: Electronic Edition, 2012, 2(1): 1-3.
Zhai Yaqi, Linghu Enqiang, Li Huikai, et al. A comparative study of endoscopic tunneling and conventional mucosal dissection in the treatment of large superficial tumors of the esophagus[J].Journal of Southern Medical University,2014,34(1):36 -40.
Wu P,Wang F,Wu X,etal.Comparison of esophageal stent placement versus endoscopic incision method for treatment of refractory esophageal anastomotic stricture[J].Ann Palliat Med,2019,8(4):462-468.
Tano T,Yoda Y,Satake H,etal.Radial incision and cutting method for refractory stricture after nonsurgical treatment of esophageal cancer [J].Endoscopy,2013,45(4):316-319.
Wang Junmin, Zhu Xinying, Zhao Wenjuan. A prospective comparative study of segmented compliant fully peritoneal retractable esophageal stents and traditional esophageal stents for malignant esophageal strictures [J]. Chinese Journal of Digestive Endoscopy, 2020,37(7):507-509.
Zhang Wenbin, Guo Bin, Chen Xing, et al. Study on the treatment of refractory esophagogastric anastomotic stenosis with a new type of ultra-covered metal stent[J].Modern Digestive and Interventional Diagnosis and Treatment, 2018,23(1):28-30.
Aibe T,Fuji T,Okita,et al.A fundamental study of normal layer structure of the gastrointestinal wall visualized by endoscopic ultrasonography[J].Scand J Gastroenterol Suppl,1986,123:6-15.
Yang Ying, Chen Bingfang, Ding Yanbo. Application of microprobe ultrasound combined with endoscopic ultrasound in the diagnosis and treatment of unexplained esophageal stricture lesions [J]. Chinese Journal of Digestive Endoscopy, 2017, 34(10): 740-742.
Wang Zhenbiao, Wu Yanjing, Zhang Yuening, et al. Analysis of the influencing factors of esophageal stricture caused by sclerotherapy of esophageal varices[J]. Journal of Clinical Hepatobiliary Diseases, 2017, 33(9): 1722-1724.

No competing interests reported.

Datesofthetencases.xls

PDF

Reviewers agreed at journal
07 May, 2022
Reviews received at journal
30 Apr, 2022
Reviews received at journal
30 Apr, 2022
Reviewers agreed at journal
21 Apr, 2022
Reviewers agreed at journal
19 Apr, 2022
Reviews received at journal
17 Apr, 2022
Reviews received at journal
12 Apr, 2022
Reviewers agreed at journal
10 Apr, 2022
Reviewers agreed at journal
09 Apr, 2022
Reviews received at journal
09 Apr, 2022
Reviewers agreed at journal
30 Mar, 2022
Reviewers agreed at journal
19 Mar, 2022
Reviewers agreed at journal
06 Mar, 2022
Reviewers invited by journal
05 Mar, 2022
Editor assigned by journal
05 Mar, 2022
Editor invited by journal
04 Mar, 2022
Submission checks completed at journal
04 Mar, 2022
First submitted to journal
03 Mar, 2022

You are reading this latest preprint version

Ultrasoic endoscopy guiding to cut scar of esophageal stricture after variceal sclerotherapy

Status:

Version 1

Abstract

Figures

Introduction

Method

Object

Inclusion criteria

Exclusion criteria

Assessment

Endoscopic treatment

Result

Discussion

Conclusion

Abbreviations

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors’ contributions

Acknowledgements

References

Competing Interests

Supplementary Files

Status:

Version 1