A randomized controlled trial of endoscopic steroid injection for prophylaxis of esophageal stenoses after extensive endoscopic submucosal dissection

Abstract

BackgroundEsophageal stenosis following endoscopic submucosal dissection (ESD) is a serious adverse event that makes subsequent management more difficult.MethodsThis parallel, randomized, controlled, open-label study was designed to examine whether local steroid injection is an effective prophylactic treatment for esophageal stenoses following extensive ESD. This single center trial was conducted at the Keiyukai Hospital, a tertiary care center for gastrointestinal disease in Japan [University Hospital Medical Network Clinical Trial Registry (UMIN-CTR) on 15 September 2011 (UMIN000006327)]. Thirty-two patients with mucosal defects involving ≥75% of the esophageal circumference were randomized to receive a single dose of triamcinolone acetonide injections (n = 16) or be treated conventionally (n = 16). The primary outcome was the frequency of stricture requiring endoscopic dilatation; the surrogate primary endpoint was the number of dilatation sessions needed. Secondary outcomes included adverse event rates, the minimum diameter of the stenotic area and the duration of the course of dilatation treatments.ResultsThe frequency of stricture was not significantly different between the groups because of insufficient statistical power, but the number of dilatation sessions required was significantly less in the steroid group (6.1 sessions [95% confidence interval, CI 2.8–9.4] versus 12.5 [95% CI 7.1–17.9] sessions in the control group; P = 0.04). The perforation rate was similar in both groups. The minimum diameter of stenotic lumens was significantly greater in the treatment group than controls (11.0 mm versus 7.1 mm, respectively; P = 0.01). The perforation rate was not significantly different between the groups (1.0% versus 0.5% in the treatment and control group, respectively). Steroid injection was effective in cases of mucosal defects encompassing the entire esophageal circumference.ConclusionsProphylactic endoscopic steroid injection appears to be a safe means of relieving the severity of esophageal stenoses following extensive ESD.

Review of antireflux procedures for proton pump inhibitor nonresponsive gastroesophageal reflux disease

“…52, 59 Liang et al , utilizing a 6-point Likert scale to measure the frequency and severity of symptoms, found a significant improvement in heartburn scores and regurgitation scores 5 years after RFED therapy. 53 Studies reported a wide range for patients with complete PPI cessation (6.3–86%), though overall PPI use was reduced in 43–89% of patients. 52–57 …”

Clinical Analysis of Esophageal Stricture in Patients Treated with Intralesional Triamcinolone Injection after Endoscopic Submucosal Dissection for Superficial Esophageal Cancer

“…Since esophageal stricture sometimes worsens quality of life, various preventive methods have been proposed [4,7,10] . Endoscopic injection of TA is widely used in the prevention of esophageal stricture associated with ESD [8,9] . However, a significant population of patients develop esophageal stricture even after the preventive injection.…”

“…Endoscopic TA injection is one of the most effective treatments for prevention of ESD-associated esophageal stricture [8,9] . However, a significant proportion of patients still develop esophageal stricture requiring EBD even after endoscopic TA injection.…”

“…Although endoscopic TA injection can cause delayed perforation upon injection into the muscle layer [6,7] , several clinical studies report the safety and efficacy of its use [8,9] . It should be noted, however, that a significant proportion (10-20%) of patients still develop postoperative esophageal stricture even after treatment with endoscopic TA injection [8,9] . Therefore, it is important to identify the subgroup of patients at high risk of developing ESD-related esophageal stricture after TA injection.…”

Current Status and Future Prospects for Esophageal Cancer Treatment

“…They concluded that oral steroid therapy after EBD is an effective strategy for the management of esophageal strictures after complete circumferential ESD. The local injection of triamcinolone acetonide 18) and other systemic steroid therapies 13) are frequently used to prevent esophageal strictures after ESD. Moreover, ESD for esophageal cancer is generally a more difficult technique as compared to ESD for gastric cancer because the working space is small in esophageal ESD.…”