Prevention of Stricture after Endoscopic Submucosal Dissection for Superficial Esophageal Cancer: A Review of the Literature

Local triamcinolone injection and selective add-on oral steroids to prevent esophageal post-endoscopic submucosal dissection stricture: a retrospective analysis in a Western center

BACKGROUND

Extensive esophageal endoscopic submucosal dissections (ESDs) without preventive measures carry a high risk of stricture. Oral steroids and local injection of triamcinolone acetonide have proven to be effective in Asia for the prevention of esophageal stricture. This study aimed to assess the efficacy of a systematic steroid administration protocol for stricture prevention in a Western center.

METHODS

A retrospective review was conducted of all esophageal ESDs performed at H.U.B. Erasme Hospital, Brussels between 2016 and 2022. Injection of triamcinolone was performed for mucosal defects between 50% and 89% of the circumference. We added oral corticosteroids for patients with resections of ≥90% of the circumference. The primary outcome was the incidence of symptomatic stenosis at 3 months. Secondary outcomes included the cumulative stricture rate assessed by endoscopy within 6 months of ESD. Potential risk factors of stricture were evaluated with univariate and multivariate analysis.

RESULTS

111 patients underwent 130 esophageal ESDs, with 59 patients receiving triamcinolone acetonide local injection and eight receiving local and oral corticosteroids. The primary outcome demonstrated a stricture incidence of 8.4%. The cumulative stricture rate assessed by endoscopy within 6 months of ESD was 10.4%. A mucosal defect of ≥60 mm in length was associated with a 15-fold increased risk of stricture, with circumferential extent also identified as being an independent prognostic factor for stricture.

CONCLUSIONS

Our protocol led to a low stricture rate, even after extensive resection. As a single session treatment without systemic side effects, triamcinolone injection could provide benefits as a preventive method after large esophageal resections.

Progress in the treatment and prevention of esophageal stenosis after endoscopic submucosal dissection

The primary treatment for early esophageal cancer and precancerous lesions is endoscopic submucosal dissection (ESD). However, this approach leads to a high incidence of postoperative esophageal stenosis, which can significantly impact a patient's quality of life. While various methods are available to prevent post-ESD esophageal stenosis, their effectiveness varies. Therefore, this study aims to provide an overview of the currently employed methods for preventing post-ESD esophageal stenosis in clinical practice in view of assisting clinical practitioners.

Curative criteria for endoscopic treatment of oesophageal squamous cell cancer

Endoscopic treatment of early oesophageal squamous cell carcinoma is widely accepted. ESD (Endoscopic Submucosal Dissection), which allows en bloc resection regardless of size, provides resected specimens that facilitate histological evaluation of curability. In the histological investigation, the determination of tumor depth, lymphovascular involvement, and lateral and vertical margins play a great role in the assessment of curability. The diagnosis of lymphovascular invasion, in particular, is enhanced by the addition of immunostaining. The long-term outcome of ESD is comparable to that of oesophagectomy, and ESD may be the first-line treatment for early-stage oesophageal cancer due to its fewer complications. Surveillance after curative resection is also imperative because oesophageal cancer is often characterized by the concept of field cancerization, which results in metachronous multiple primary lesions.

A novel risk score model of esophageal stricture for patients undergoing endoscopic submucosal dissection

BACKGROUND AND PURPOSE

Endoscopic submucosal dissection (ESD) is a promising technique for superficial esophageal lesions. However, stricture is a frequent adverse complication. This study was performed to develop a precise and convenient score prediction model for esophageal strictures after ESD, and compare its efficacy with a previously published predictive model.

METHODS

This study enrolled clinical data of patients who underwent esophageal ESD for superficial esophageal lesions. Possible risk factors for esophageal stricture were identified by univariate and multivariate logistic regression analysis. Then we developed a prediction model according to the Framingham system for the first time and presented a convenient table containing the risk probability for each patient. In addition, we validated our score model and the previously published model in our center.

RESULTS

A total of 838 patients were enrolled in this study and 6 variables, including age, surgery time, location of the lesion, circumference of the lesion, longitudinal resection length, and depth of infiltration were comprised in the score model. The total score ranged from 0 to 16 points and the risk probability was presented in one concise table for each patient. Areas under receiver-operator characteristic curves for the prediction model were 0.715 in derivation group and 0.804 in validation group.

CONCLUSION

We designed and validated a prediction score model for esophageal stricture after ESD, which can be applied conveniently to stratify the stricture risk after esophageal ESD and may facilitate appropriate clinical decision-making for these patients.

Prevention of esophageal stricture after endoscopic submucosal dissection of squamous cell carcinoma using a 20-French nasogastric tube combined with oral steroid administration

BACKGROUND

Esophageal stricture is a major complication after esophageal endoscopic submucosal dissection (ESD) and when the mucosal defect exceeds 3/4 of the circumference. Various preventive methods have been reported to prevent stenosis. However, in the case of circumferential ESD, there is no way to prevent luminal stenosis effectively. This retrospective study aimed to evaluate the efficacy of 20-French nasogastric tubes (NGT) combined with oral steroids for the prevention of esophageal stricture after endoscopic submucosal dissection.

METHODS

Between January 2012 and December 2021, we enrolled 57 patients with post-ESD mucosal defects exceeding 3/4 of the esophageal circumference. Of them, the initial seven patients received oral steroid therapy and the subsequent 50 patients received 20-French NGT placements combined with oral steroid therapy. We retrospectively evaluated the rates of strictures and refractory strictures and explored risk factors for strictures with 20-French NGT.

RESULTS

The overall esophageal stricture rate was 42.1% (24/57). In the noncircumferential group, the esophageal stricture rate in patients with only oral steroid to prevent esophageal stricture was 85.7% (6/7), while the esophageal stricture rate was only 4.3% (1/23) in those with 20-French NGT placements and oral steroid. All 27 patients with whole-circumferential resection received 20-French NGT placements. The stricture rate was 63.0% (17/27), and the refractory stricture rate was 17.6% (3/27).

CONCLUSION

Using a 20-French NGT placement combined with oral steroid administration is an easy and safe alternative to prevent esophageal stricture after ESD, especially for patients with noncircumferential mucosal defects. Further studies are needed to develop an effective stricture prevention method for post-ESD whole-circumferential mucosal defects of the esophagus.

Successful prevention of stenosis after circumferential endoscopic resection of esophageal cancer

Circumferential resection of a >5-cm longitudinal mucosal defect following esophageal endoscopic submucosal dissection (ESD) is a risk factor for refractory stenosis. Circumferential ESD was performed in 3 patients with 64, 69, and 70 mm longitudinal mucosal defects. A local steroid injection was used to treat the postoperative ulcer, followed by an oral steroid. In all three cases, the ulcer healed without the need for endoscopic dilation. A combination of local injection and oral steroids effectively prevented esophageal stenosis in patients with high-risk stenosis after ESD.

Association between Submucosal Fibrosis and Endoscopic Submucosal Dissection of Recurrent Esophageal Squamous Cell Cancers after Chemoradiotherapy

Simple Summary

The efficacy and safety of endoscopic submucosal dissection for early esophageal cancer after chemoradiotherapy have not been established. In this study, we focused on the fibrosis of the submucosa. As a result, we found that endoscopic submucosal dissection for early esophageal cancer can be performed reliably without adverse events, but the procedure takes longer for lesions with strong fibrosis of the submucosa.

Abstract

Endoscopic resection is a treatment of choice for a metachronous early-stage esophageal squamous cell carcinoma (ESCC) appearing after a radical cure of esophageal cancer by chemoradiotherapy (CRT). However, non-curative resection, and procedural complications including perforation due to radiation-induced submucosal fibrosis, are a concern. This study aimed to evaluate the association between submucosal fibrosis and the usefulness and safety of endoscopic submucosal dissection (ESD) in ESCC after CRT. This study retrospectively analyzed 13 lesions in 11 patients in our institute. Submucosal fibrosis under the lesion (F score) was classified into three levels (F0: none or mild, F1: moderate, and F2: severe) based on endoscopic and histopathologic findings. All lesions were F1 or greater (F1: 8 lesions and F2: 5 lesions). En bloc and R0 resection rates were both 100%. The procedural speed was slower in F2 than in F1 (F1 vs. F2; 15.1 mm²/min vs. 7.1 mm²/min, p = 0.019), without procedure-related adverse events. At a median follow-up of 42 months (range: 14–117 months) after ESD, 7 of 11 (63.6%) patients were alive without recurrence, and without ESCC-related death. ESCC after CRT reliably and safely resected en bloc by ESD but was more difficult in lesions with strong submucosal fibrosis.

Advances in the application of regenerative medicine in prevention of post-endoscopic submucosal dissection for esophageal stenosis

Endoscopic submucosal dissection (ESD) is a curative treatment for superficial esophageal cancer with distinct advantages. However, esophageal stenosis after ESD remains a tough problem, especially after large circumferential proportion of esophageal mucosa is removed, which limits the wide use of ESD, especially in circumferential lesions. In this scenario, preventive procedures are highly recommended against post-ESD esophageal stenosis. However, the efficacy and safety of traditional prophylactic methods (steroids, metal and biodegradable stents, balloon dilation, radial incision, etc.) are not satisfactory and novel strategies need to be developed. Regenerative medicine has been showing enormous potential in the reconstruction of organs including the esophagus. In this review, we aimed to describe the current status of regenerative medicine in prevention of post-ESD esophageal stenosis. Cell injection, cell sheet transplantation, and extracellular matrix implantation have been proved effective. However, numerous obstacles still exist and further studies are necessary.

Predictors of recurrence of dysplasia or cancer in patients with dysplastic Barrett's esophagus following complete eradication of dysplasia: a single-center retrospective cohort study

BACKGROUND AND AIMS

Endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) for Barrett's esophagus (BE)-related high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EAC) are considered effective treatments for eradication of BE. Little is known about the impact of achieving complete eradication of intestinal metaplasia (CE-IM) following the complete eradication of neoplasia (CE-N), specifically if CE-IM reduces the risk of recurrent dysplasia.

METHODS

Retrospective cohort study of consecutive patients with BE and HGD or intramucosal cancer (IMC)-treated endoscopically at a tertiary referral center between 2001 and 2019. Association between CE-IM and recurrent dysplasia after CE-N was evaluated.

RESULTS

A total of 433 patients treated with EMR and/or RFA were included. Of these, 381 (88%) achieved CE-N, of which 345 (80%) had adequate follow-up for inclusion in the analysis. A total of 266 (77%) patients achieved CE-IM; with a median follow-up since initial treatment for HGD/IMC of 45.9 months (IQR 25.9, 93.1); 20 patients (5.8%) had recurrent dysplasia after achieving CE-N. Kaplan Meier survival curves revealed that time free of recurrence in those who achieved CE-IM was significantly higher (p = 0.002). In the multivariable analysis, CE-IM was associated with a significant lower hazard of recurrence (HR 0.2, 95% CI 0.1, 0.6), whereas the number of endoscopic treatments to achieve CE-N was associated with a significant higher hazard of recurrence (HR 1.1, 95% CI 1.0, 1.2).

CONCLUSION

Achieving CE-IM following CE-N reduces the risk of recurrent dysplasia and should be considered a treatment target among patients with BE undergoing endoscopic therapies for HGD or EAC.

Stent placement to prevent strictures after esophageal endoscopic submucosal dissection: a systematic review and meta-analysis

Endoscopic submucosal dissection (ESD) is an important method for the treatment of early esophageal cancer. However, post-procedure stenosis is one of the most common long-term complications. This meta-analysis aimed to investigate whether stent placement is effective in the stenosis prevention, and which type of stent would be more effective. A systematic and electronic search of clinical trials and observational studies conducted before March 2020 on the efficacy of stent placement in preventing esophageal stricture after ESD was performed. Search terms included "ESD," "esophageal stenosis," "esophageal stricture," and "stents." We conducted a bias risk assessment of the eligible reports and a meta-analysis of the data using Revman 5.3 software. We included two randomized controlled trials (RCTs) and a prospective cohort study involving 163 patients with esophageal mucosal defects encompassing at least three-quarters of the esophagus circumference after ESD. The meta-analysis results showed that post-ESD stenosis rates (RR, 0.37; 95% CI, 0.22-0.64; P = 0.0003) and the number of endoscopic balloon dilations (EBDs) (MD, -1.74; 95% CI, -2.46 to -1.01; P < 0.00001) were reduced in the pooled analysis of three studies, indicating that stent placement was effective for stenosis prevention, especially a polyglycolic acid (PGA) sheet combined with stent placement can prevent stenosis (RR, 0.41; 95% CI, 0.23-0.74; P = 0.003) and reduce the number of EBDs (MD, -1.65; 95% CI, -2.40 to -0.90; P < 0.0001) significantly. Stent placement can reduce the rate of esophageal stenosis after ESD, especially when stents are covered with PGA sheets. However, more high-quality, low-bias RCTs with a sufficient sample size are needed to demonstrate its effectiveness.

Topical oro-dispersible budesonide tablets for stricture prevention after near circumferential ESD for esophageal squamous cell cancer - a case report

BACKGROUND

 Endoscopic resection is the treatment of choice for early esophageal cancers. However, resections comprising more than 70-80 % of the circumference are associated with a high risk of stricture formation. Currently, repetitive local injections and/or systemic steroids are given for prevention.

CASE REPORT

 We present here the case of a 78-year-old male patient who had a near circumferential endoscopic submucosal dissection for a pT1a mm, L0, V0, R0, G2 esophageal squamous cell cancer. At the end of endoscopic resection, 80 mg of triamcinolone was injected locally. The patient was then treated with oro-dispersible budesonide tablets (2 × 1 mg/day) and nystatin (4 × 100 000 I.E.) for 8 weeks. This treatment resulted in complete healing without any stricture formation and did not result in any complications.

DISCUSSION

 Treatment with orodispersible budesonide tablets could help prevent strictures after large endoscopic resections in the esophagus.