Prediction of esophageal stricture in patients given locoregional triamcinolone injections immediately after endoscopic submucosal dissection

Background and Aim The esophageal triamcinolone acetonide (TA)‐filling method is a novel local approach for stenosis prevention after extensive esophageal endoscopic submucosal dissection (ESD). We evaluated this method after subcircumferential ESD. Methods We enrolled 20 patients with esophageal cancer requiring subcircumferential ESD in a prospective multicenter study. Esophageal TA filling was carried out 1 day and 1 week after ESD, with follow‐up endoscopy every 2 weeks. We treated severe stenosis preventing endoscope passage with endoscopic balloon dilatation (EBD) and additional TA filling, and mild stenosis allowing endoscope passage with additional TA filling only. Primary endpoint was incidence of severe stenosis; secondary endpoints were total number of EBD, rate of additional TA filling, time to stenosis and complete re‐epithelialization, dysphagia score, and adverse events. Horizontal resection grade was divided into grades 1 (≥ 9/12 and <10/12 of the circumference), 2 (≥ 10/12 and <11/12), and 3 (≥ 11/12 but not circumferential) and analyzed statistically for correlation with endpoints. Results Incidence of severe stenosis was 5.0% (1/20; 0.1–24.8%) and was treated with three EBD. Six patients showed mild stenosis. Additional TA filling was carried out in these seven patients: 0% (0/9) for grade 1 resection, 40% (2/5) for grade 2, and 83% (5/6) for grade 3 (P < 0.05). Median time to stenosis and re‐epithelialization was 3 and 7 weeks, respectively. Dysphagia score deteriorated in one patient. No adverse events occurred. Conclusions The esophageal TA‐filling method prevented stenosis after subcircumferential ESD. Grade ≥2 resection showed a high risk for stenosis, but additional TA filling for mild stenosis inhibited stenosis progression (UMIN000024384).

Section: Discussionmentioning

confidence: 99%

Prospective multicenter study of the esophageal triamcinolone acetonide‐filling method in patients with subcircumferential esophageal endoscopic submucosal dissection

Shibagaki

Yuki

Taniguchi³

et al. 2019

“…Esophageal stricture is a major challenge for endoscopists who carry out esophageal ESD. Despite unremitting effort and investigation over the years, the stricture rate in patients with circumferential resection has not obviously decreased . Yoshiki et al .…”

Section: Discussionmentioning

confidence: 99%

Clinical experience of using a novel self‐help inflatable balloon to prevent esophageal stricture after circumferential endoscopic submucosal dissection

Linghu

Chai

et al. 2019

Although endoscopic submucosal dissection (ESD) is gradually becoming a first‐line treatment for superficial esophageal neoplasms (SEN), strictures occur in almost 100% of cases after circumferential ESD. A standard method to prevent stricture has not been established. Thus, we propose a novel self‐help inflatable balloon to prevent stricture. The new balloon was used by the patients themselves at home (4–5 times a day, duration of each procedure was approximately 15–20 min), and was removed when the defects were almost healed. From January 2018 to September 2018, eight patients who received circumferential ESD for SEN and underwent a novel self‐help inflatable balloon to prevent stricture were enrolled. Median size of the mucosal defects was 76.3 mm (range: 50–90 mm). Median time for removing the self‐help inflatable balloon was 94.6 days (range, 71–119 days). Only one (12.5%) patient experienced stricture, and three endoscopic balloon dilation sessions were carried out for this patient. All patients tolerated the balloon well, and none experienced perforation or delayed bleeding. The self‐help inflatable balloon seems to show a high preventive effect against stricture in patients whose mucosal defect was no longer than 100 mm in length after esophageal circumferential ESD. This method is economic, feasible, and safe.

“…Local TA injection for noncircumferential lesions showed favorable outcomes in some studies, whereas stricture rates were rather high in other studies (Table ) . In the assessment of treatment efficacy, extent of mucosal defect may affect stricture rates.…”

Section: Steroid Therapymentioning

confidence: 99%

“…Combination treatment involving oral steroid administration and local TA injection is also being evaluated at some facilities . Both oral steroid administration and local TA injection showed favorable effects for noncircumferential lesions (Table ) . Some researchers have stated that local TA injection requires a highly skilled technique; however, it is not difficult for endoscopists who can carry out ESD for large lesions.…”

Section: Steroid Therapymentioning

confidence: 99%

“…Even after prevention, stricture sometimes develops after ER. Risk factors for stricture after local TA injection are reported to be: (i) mucosal defects of ≥5/6; or (ii) tumor extent of ≥3/4 . Risk factors for stricture after oral steroid administration are reported to be: (i) mucosal defects of ≥11/12; (ii) longitudinal diameter of ≥50 mm; (iii) lesion in the cervical esophagus; and (iv) history of chemoradiotherapy .…”

Section: Management Of Stricturementioning

confidence: 99%

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Prevention of esophageal stricture after endoscopic resection

Ishihara

2019

Stricture formation after esophageal endoscopic resection has a negative impact on patients’ quality of life because it causes dysphagia and requires multiple endoscopic dilations. Various methods by which to prevent stricture have recently been developed and reported. Among these methods, local steroid injection is the most commonly used and is currently considered the standard method for noncircumferential resection. However, local steroid injection has a limited effect on circumferential resection. Thus, oral steroid administration is used for such cases because it may have a stronger effect than local injection. Steroid treatment, both by local injection and oral administration, is effective and low‐cost; however, it may cause fragility of the esophageal wall, resulting in adverse events such as perforation during balloon dilatation. Many innovative approaches have been developed, such as tissue‐shielding methods with polyglycolic acid, tissue engineering approaches with autologous oral mucosal epithelial cell sheet transplantation, and stent insertion. These methods may be promising, but they are limited by a scarcity of data. Further investigations are needed to confirm the efficacy of these methods.