Transplantation of Autologous Cell Sheets After Endoscopic Submucosal Dissection (ESD) for Early Adenocarcinoma of the Esophagus

Aim Our aim is to evaluate if mucosal wound healing after endoscopic resection of early cancers or pre-cancerous lesions in the esophagus can be enhanced by transplantation of autologous cell sheets, thus reducing the risk of esophageal stenosis.

Background Adenocarcinoma and Barrett's esophagus The incidence of esophageal adenocarcinoma (EAC) has increased rapidly in the western world during the last decades. The reason for this increase is unknown, however, there is a strong association between the risk of developing EAC and gastro esophageal reflux. Chronic reflux may lead to Barrett's esophagus (BE), a condition where the squamous epithelium of the esophagus is replaced by columnar epithelium(1). BE is a premalignant condition with a lifetime risk of progressing to EAC of 5% in men and 3% in women (2).

The rate of progression is dependent on the grade of dysplasia in BE. One meta-analysis showed that low-grade dysplasia had a cancer incidence of 17/1,000 patient-years while high-grade dysplasia had an incidence of 66/1,000 patient-years (3). Medical treatment can reduce reflux symptoms, but there is no proof that it can decrease the risk of progression.

Treatment High-grade dysplasia The American Gastroenterological Association guidelines recommend that patients with high-grade dysplasia should be treated with surgical resection, endoscopic therapy or be offered surveillance with endoscopy every 3 months (4).

The Japanese Society for Gastrointestinal Endoscopy (JGSE) has described that endoscopic mucosal resection (EMR) is suitable for BE with high-grade dysplasia given that the diameter is ≤2 cm, < 1/3 of the esophageal circumference and limited to the mucosa. One of several advantages with EMR is that the resected mucosa can be examined histologically, compared to ablative therapies. Briefly, EMR is performed by submucosal injection to separate esophageal wall layers and then resection of the mucosa with a snare. A similar technique is endoscopic submucosal dissection (ESD) which also includes a submucosal injection, but instead of using a snare for resecting, the lesion is dissected with cutting instruments, such as the insulation-tipped (IT) knife.