The Healing Process of Gastric Artificial Ulcers After Endoscopic Submucosal Dissection

Abstract

Background: Due to the remarkable progress of endoscopic resection techniques, endoscopic submucosal dissection (ESD) has been widely performed for larger mucosal tumors that would result in large artificial ulcers. The healing process of peptic ulcers has been previously studied in detail; however, no precise investigation for artificial ulcers after ESD has been reported. To confirm the validity of the treatment from the aspect of wound healing, we aimed to clarify the healing process of large gastric artificial ulcers after ESD. Methods: Seventy patients with gastric mucosal tumors treated by ESD were enrolled. The size, location and time of scar formation of the ulcers were reviewed using endoscopic pictures taken from the same view and angle. Follow-up endoscopy was performed at 1, 4, 8 and 12 weeks after ESD. For postoperative medication, all patients received normal doses of proton pump inhibitors and sucralfate for 8 weeks. Results:The average size of the resected specimen was 34.7 mm (20-90 mm). Irrespective of ulcer size and location, all of the cases healed up to scarring stages within 8 weeks. Conclusions: Gastric artificial ulcers after ESD healed within 8 weeks regardless of size and location using normal doses of medication as peptic ulcers. The fact that even giant ulcers after ESD heal within 8 weeks could be helpful information for candidates for ESD and for postoperative management of patients after ESD.

Risk Factors for Delayed Ulcer Healing after Endoscopic Submucosal Dissection of Gastric Neoplasms

“…Overall, the mean ESD procedure time was 130 min and the mean artificial ulcer size after ESD was 667 mm 2 . With regard to the rate of ulcer healing, among the 73 patients in our study group, 16 presented with an unhealed ulcer at the 8-week follow up.…”

“…The better healing of EMR-induced ulcers than that of peptic ulcers is due to the preservation of the contractility of the muscularis propria layer, which is usually damaged in the case of peptic ulcers [1]. The healing of EMRinduced ulcers might be facilitated by the increased blood supply at the margins of the ulcer, resulting from increased levels of nitric oxide, epidermal growth factor and endogenous prostaglandin [2]. However, delayed ulcer healing of >8 weeks has been reported in 5-20% of patients following ESD [3,4].…”

“…The effectiveness of vonoprazan for the treatment of post-ESD ulcers has not been systematically evaluated and there is no clinical consensus regarding potential advantages of vonoprazan treatment compared to PPIs. Moreover, PPI treatment for artificial ulcers induced by ESD is usually continued for 4-8 weeks [1,2,8]. However, there is no current consensus regarding the optimal duration of PPI or P-CAB treatment after ESD based on the various factors that can influence healing of post-ESD ulcers.…”

Endoscopic submucosal dissection for gastrointestinal neoplasms

“…A recent study showed that proton pump inhibitors more effectively prevented bleeding from the gastric ulcer created after ESD than did H2-receptor antagonists [58] . Ulcers after ESD are reported to heal within 6 to 8 wk in the esophagus, stomach and colorectum [59][60][61][62][63] . Endoscopic surveillance should be carried out in patients after ESD not only to detect local recurrence but also metachronous cancer especially in the esophagus and stomach.…”

Optimal Duration of Proton Pump Inhibitor for Healing Artificial Ulcers After Endoscopic Submucosal Dissection for Early Gastric Cancer

“…Oh et al [21] reported that the size of the initial defect affects the rate of ulcer healing at 4 weeks of PPI administration post-ESD. Kakushima et al [22] reported that 4 weeks of PPI administration was not T. Gotoda (&) Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan e-mail: tgotoda@hosp.ncgm.go.jp T. Gotoda Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan sufficient, and 8 weeks of administration was required to obtain satisfactory results for larger ulcers after ESD.…”