Management of esophageal stricture after complete circular endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma

Abstract

BackgroundEndoscopic submucosal dissection (ESD) permits removal of esophageal epithelial neoplasms en bloc, but is associated with esophageal stenosis, particularly when ESD involves the entire circumference of the esophageal lumen. We examined the effectiveness of systemic steroid administration for control of postprocedural esophageal stricture after complete circular ESD.MethodsSeven patients who underwent wholly circumferential ESD for superficially extended esophageal squamous cell carcinoma were enrolled in this study. In 3 patients, prophylactic endoscopic balloon dilatation (EBD) was started on the third post-ESD day and was performed twice a week for 8 weeks. In 4 patients, oral prednisolone was started with 30 mg daily on the third post-ESD day, tapered gradually (daily 30, 30, 25, 25, 20, 15, 10, 5 mg for 7 days each), and then discontinued at 8 weeks. EBD was used as needed whenever patients complained of dysphagia.ResultsEn bloc ESD with tumor-free margins was safely achieved in all cases. Patients in the prophylactic EBD group required a mean of 32.7 EBD sessions; the postprocedural stricture was dilated up to 18 mm in diameter in these patients. On the other hand, systemic steroid administration substantially reduced or eliminated the need for EBD. Corticosteroid therapy was not associated with any adverse events. Post-ESD esophageal stricture after complete circular ESD was persistent, requiring multiple EBD sessions.ConclusionsUse of oral prednisolone administration may be an effective treatment strategy for reducing post-ESD esophageal stricture after complete circular ESD.

Endoscopic submucosal dissection for superficial esophageal squamous cell neoplasms

“…Isomoto et al [54] described seven patients with superficial SCC who underwent completely circumferential ESD. Of the seven patients, four were treated with an 8 wk course of oral prednisolone that was administered at a dose of 30 mg daily on the third post-ESD day and tapered off gradually (30 Administration of oral prednisolone effectively either prevented esophageal stricture or reduced the number of EBD sessions.…”

“…In a retrospective study in 41 patients with esophageal stricture after complete circular or semicircular ESD for esophageal SCCs involving more than threequarters of the lumen, Yamaguchi et al [55] compared an oral prednisolone group with a pre-emptive EBD group. Oral prednisolone was administered as in Isomoto et al [54] 's report. Pre-emptive EBD was started on the third day post-ESD and continued twice weekly for 8 wk.…”

Management of strictures after endoscopic submucosal dissection for superficial esophageal cancer

“…Therefore, sufficient preoperative explanation and prevention of stenosis are necessary." And, it is now becoming possible to treat the whole circumference lesion via ESD and to control the stenosis (14). Table 2 shows prevention methods of post-procedural strictures by steroids.…”

Current Status and Future Prospects for Esophageal Cancer Treatment

“…4) Subcircumferential or circumferential ESD was performed in the clinical setting in patients who were hoped would not have to undergo esophagectomy or patients with severe comorbidities. 12,13) Thereafter, most of these patients required several sessions of dilation because of severe/refractory dysphasia although their preoperative conditions were asymptomatic. Repeated dilation has the potential risk of tears/ perforation, which results in potentially lethal complications and worsens the quality of life (QOL).…”

“…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.…”