Side-Opening Cutting Forceps Safe, Reliable for Use in Pediatric EoE

Use of side-opening cutting forceps was shown to be safe and more reliable for biopsies of the esophageal lamina propia (ELP) compared with standard pediatric alligator jaw biopsy forceps among pediatric patients with eosinophilic esophagitis (EoE) when needing to determine degree of fibrosis from the inflammatory disease.

The patient population for this study had either active EoE (n = 15) or remitted EoE (n = 12). All received care through the Primary Children’s Hospital Food Allergies and Eosinophilic Disorders Program at the University of Utah and had been recommended to undergo an upper endoscopy with biopsy to determine EoE status. Patients in the active EoE group were slightly younger at diagnosis and in the study vs the group with remitted EoE: 5.07 and 8.73 years, respectively, vs 6.33 and 9.25 years.

With data on side-opening cutting forceps showing above a 90% diagnostic rate for tissue biopsy in adult patients with EoE who undergo biopsy of the ELP, but previous research also showing just a 50% evaluation rate of ELP samples in pediatric patients with EoE, investigators conducted a pilot study on use of side-opening cutting forceps in younger patients. Their findings were published recently in Clinical Endoscopy.¹

Endoscopic reference score (EREFS) was used during the biopsy for visual assessment, and patients charts were reviewed post biopsy for any complications (eg, pain, dysphagia, significant bleeding). EREFS ranges from 0 to 18, and higher scores indicate greater disease severity.²

“Clinical pathologists reviewing biopsies were not alerted to the use of side-opening forceps,” the study authors wrote, “and gave standard histopathology reports, including eosinophils per high-power field (HPF).”

Following at least 4 esophageal biopsies per patient, 75% of the patients had adequate ELP for assessment. Peak eosinophil count was found to be significantly elevated among those with active EoE compared with remitted EoE, at 57/hpf vs 2/hpf. In addition, 73.3% of the active EoE group had lamina propia noted as present in their pathology report compared with none in the remitted-EoE group, and 81.8% of the active EoE group but none in the remitted EoE group had demonstrated fibrotic LP in their pathology report.

If fibrosis was present, EREFS was 4.67 in the active-EoE patient group and not applicable in the remitted EoE patient group. However, if fibrosis was not present in the ELP biopsy sample, the EREFS dropped to 3 in the active-EoE group and was shown to be 0.58 in the remitted EoE group.

Three patients shown to have ELP fibrosis also had evidence of abnormal esophageal architecture (ie, stenosis or stricture) or were shown to have rings. No adverse events were reported.

The study investigators emphasized that their use of the side-opening forceps produced higher ELP yield compared with earlier studies because of “orienting the mobile open side perpendicular to the mucosa, followed by suction, allowing for the cutting action of the forceps to penetrate deeper into the lamina propria as they are closed.”

Also, because the side-opening forceps are reusable, there is potential for cost savings on the part of the patients who must undergo repeated esophagoscopy and could be billed for each single-use disposable forceps. The authors did note, however, that single-use forceps “carry a significantly lower infection risk that reusable forceps.”

Limitations on these findings include the small sample size and a patient population from a single medical center.

“Obtaining ELP biopsy samples for every patient could result in better individualized treatments resulting in better patient-centered outcomes, as well as the determination of future treatment policies or prediction of prognosis,” the study authors concluded. “Future studies should focus on the use of side-opening forceps in larger pediatric cohorts (including intrasubject repeated measures in treated patients), with specific attention paid to which treatments have the greatest ability to resolve ELP fibrosis in those with early evidence of this issue.”

Reference

1. Cardullo AT, Robson JO. Side-opening cutting forceps and esophageal lamina propria yield in pediatric patients with eosinophilic esophagitis. Clin Endosc. Published online June 28, 2023. doi:10.5946/ce.2023.008

2. Dupixent. Sanofi and Regeneron Pharmaceuticals. Updated June 2023. Accessed July 31, 2023. https://tinyurl.com/3se3n8rs