Single Locoregional Triamcinolone Injection Immediately After Esophageal Endoscopic Submucosal Dissection Prevents Stricture Formation

Abstract

Objectives:Although endoscopic submucosal dissection (ESD) is an efficient treatment for superficial esophageal cancer, it is associated with stricture formation after wide-circumference resection that leads to a low quality of life. Although locoregional steroid injections prevent stricture formation, a randomized comparative study did not report any advantages associated with steroid injection. We evaluated the prophylactic efficacy of a single locoregional triamcinolone injection for stricture formation after esophageal ESD.Methods:This was a retrospective matched case-control study using propensity score matching (PSM). Between April 2006 and July 2015, a total of 602 patients with superficial esophageal neoplasia underwent ESD. Among them, 189 patients with mucosal defects that spanned more than 2/3 of the esophageal circumference were included. After exclusion, 150 patients were enrolled. Triamcinolone acetonide (80 mg) was injected into the residual submucosal layer of the resected region immediately after ESD. PSM was performed to reduce the effects of selection bias for steroid injection. The primary outcome was the incidence of stricture formation. The secondary outcome was the number of balloon dilatation procedures required to resolve the stricture formation.Results:Thirty-seven patients, with and without triamcinolone injection each, were matched after PSM. The incidence of stricture formation decreased from 45.9% (17/37) without triamcinolone injection to 18.9% (7/37) with triamcinolone injection (p=0.016). After matching, the mean number of balloon dilatation procedures required also decreased from 2.8±4.6 to 0.6±1.5 times (P<0.01).Conclusions:A single locoregional triamcinolone injection efficiently prevented stricture formation after esophageal ESD.

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

“…First, this is the first study to investigate predictive factors for stricture formation in patients who received prophylactic locoregional triamcinolone injections after ESD. Stricture formation rate of patients who have received locoregional triamcinolone injections in the present study (16.8%) was similar to that of previous studies (10–20%) . A tumor circumferential extent >75% has been reported as a risk factor for refractory stricture development, which was defined as the requirement for more than three sessions of EBD to resolve the stricture, even in cases who have received locoregional triamcinolone injections .…”

“…Locoregional steroid injections may prevent stricture formation after esophageal ESD . Giving locoregional corticosteroids may inhibit collagen synthesis, fibrosis, and inflammation .…”

“…Locoregional steroid injections may prevent stricture formation after esophageal ESD. [11][12][13][14][15] Giving locoregional corticosteroids may inhibit collagen synthesis, fibrosis, and inflammation. 26 Although several methods for giving the steroid injections have been described, [11][12][13][14][15]27 a single session of triamcinolone injections given immediately after ESD is more straightforward and less expensive, and it may have similar efficacy.…”

“…Giving prophylactic oral steroids or locoregional steroid injections is useful for preventing such strictures. [11][12][13][14][15][16] A single session of triamcinolone injections immediately after ESD may prevent stricture formation without any severe adverse events. 12,14 However, some patients develop strictures despite receiving locoregional triamcinolone injections, and the predictive factors associated with stricture formation in these cases have not yet been determined.…”

Management of adverse events related to endoscopic resection of upper gastrointestinal neoplasms: Review of the literature and recommendations from experts

“…5 Steroid therapy decreases stricture better than preventive EBD. 11 Efficacy of prophylactic steroid injection for post-ESD ulcer was reported in four observational studies [12][13][14][15] (Table 1). Most studies reported that steroid injection decreased the incidence of post-ESD stricture in high-risk patients, and one systematic review showed that injection steroid was superior to oral steroid in prevention of post-ESD stricture.…”