Risk factors of postoperative stricture after endoscopic submucosal dissection for superficial esophageal neoplasms

Abstract

Background: As larger-sized superficial esophageal neoplasms became candidates for endoscopic submucosal dissection (ESD), post-ESD esophageal stricture has inevitably developed into a significant complication during long-term follow-up. Method: The PubMed, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Web of Science, as well as China National Knowledge Infrastructure, the Wanfang Database, and the Chinese Biomedical Literature Database, were searched to identify all the appropriate studies published from January 2000 through October 2019. For risk factor assessment between postoperative stricture and control groups, pooled odds ratios (OR) and weighted mean differences (WMD) estimation was done. All meta-analytical procedures were conducted by using Stata version 15.1 software. Results: The results showed that 11 studies with 2248 patients (284 structure cases and 1964 controls) were eligible for this meta-analysis. Statistical results indicated 6 substantial risk factors: lesion characteristics involving the upper third of the esophagus (OR 1.51, [1.02–2.25]), macroscopic type of IIa/IIc (OR 2.76, [1.55–4.92]), tumor depth of invasion above m1 (OR 7.47, [3.31–16.86]), and m2 (OR 12.67, [4.00–40.10]), longitudinal length (WMD 13.75 mm, [7.76–19.74]), circumferential diameter (WMD 10.87 mm, [8.13–13.60]), and circumferential range >3/4 (OR 38.17, [9.94–146.52]). Each additional 10% of the circumferential range increased the risk of stricture by 149% (OR 9282.46, [978.14–88089.35]). Conclusions: Six risk factors were assessed to have a key role in the elevated risk levels of post-ESD esophageal stricture. The results can help doctors identify patients with increased risk and thus can guide management of the adequate period of surveillance after ESD and take available approaches of stricture prevention.

Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review

“…Endoscopic resections comprising > 50 % of the esophageal luminal circumference are prone to stricture formation, and after full circumferential resection strictures occur in almost all patients [138][139][140]. A meta-analysis found that upper third location (OR 1.5), IIa/IIc morphology (OR 2.8), tumor deeper than m1 (OR 7.5), tumor deeper than m2 (OR 12.7), circumferential extent > 3/4 (OR 38), and longitudinal length (mean difference 13.7 mm) are risk factors for stricture development [141].…”

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

“…This study demonstrates the efficacy of a systematic prospective protocol to prevent post-ESD esophageal strictures in a Western tertiary center. Without preventive measures, stricture rates can reach 70% to 100% [15], especially when the degree of resection is greater than 75% of the esophageal circumference [3,4,18]. Among the currently used preventive methods, local steroid injection and oral steroids are standard treatments since they have demonstrated efficacy for prevention of strictures and the need for endoscopic balloon dilation [4,12,13,19,20].…”

A nomogram and risk classification system predicting esophageal stricture after endoscopic submucosal dissection of a large area for early esophageal cancer

“…According to a recent review, 11 existing studies focused on predicting post‐ESD esophageal stricture 10 . However, most of these studies focused on a selection of factors, and no study has developed a nomogram yet.…”

“…Some studies have reported other risk factors, including longitudinal length of the tumor, invasion depth deeper than lamina propria mucosa (m2), and propria muscularis injury 7–9 . A recent review including 11 existing studies reported the following six substantial risk factors: lesion characteristics involving the upper third of the esophagus, IIa/IIc macroscopic Paris type, tumor invasion depth as deep as or deeper than the m2, tumor length, circumferential diameter, and circumferential range more than 75% 10 . No studies to date that include all of these relevant factors.…”

“…The predictive factors included in the nomogram can be conveniently obtained during routine clinical practice. Furthermore, the C-index of 0.79, calibration curves, DCA, and K-M curves demonstrated the excellent performance of the nomogram.According to a recent review, 11 existing studies focused on predicting post-ESD esophageal stricture 10. However, most of these studies focused on a selection of factors, and no study has developed a nomogram yet.…”