Oral steroid prophylaxis is effective in preventing esophageal strictures after large endoscopic resection

Abstract

BackgroundStrictures are frequent complications of large endoscopic mucosal resections (EMR) and endoscopic submucosal dissections of the esophagus. Local or systemic steroid therapy has shown promise in the prevention of secondary stenosis. The aim of this study was to evaluate the safety and efficacy of systemic steroid therapy following endoscopic resection of at least hemi-circumferential esophageal mucosa.MethodsThis was a single-center retrospective study in a tertiary center. We evaluated patients who were treated with oral steroids between July 2013 and September 2015, after undergoing a large EMR for Barrett’s esophagus associated with dysplasia or carcinoma. The steroid protocol used was an initial dose of 30 mg prednisolone, tapered over 8 weeks. Exclusion criteria were a previous attempt at radiofrequency ablation or resection.ResultsThirty-one patients (27 men) were analyzed: 13 with low-grade dysplasia Barrett’s esophagus, 16 with in situ adenocarcinoma, 1 with pT1SM1 adenocarcinoma, and 1 with pT1SM2 adenocarcinoma. Twenty-eight resections (28/31) were completed (R0) in 1-3 sessions (median 2), while 3 resections were R1. The median length of Barrett’s esophagus was C3M5 (range C0M2-C10M11) according to the Prague classification. The median follow up was 10 months (range 4-17), during which 4 patients (13%) developed a secondary stenosis. All stenoses were successfully treated by endoscopic dilation (range 1-4). No complications related to dilation or to the steroid therapy were observed.ConclusionsOur rate of secondary stricture was lower than expected, given the rates of 17-88% in published studies. Systemic oral steroid therapy seems to be effective in reducing potential esophageal stenosis after EMR. Complementary randomized studies are required to confirm whether systemic steroids are an effective primary prophylaxis for esophageal stenosis.

Stricture Prevention after Extensive Endoscopic Submucosal Dissection of Neoplastic Barrett’s Esophagus: Individualized Oral Steroid Prophylaxis

“…Ratone et al reported a 13% stricture rate using Yamaguchi's regime in 31 patients. However, he included resection ulcers exceeding 50% that makes interpretation of the data difficult [17]. Today, local injection of triamcinolone into the resection ulcer immediately after ESD is the preferred treatment strategy in Asia.…”

Efficacy and safety of endoscopic submucosal tunnel dissection for superficial esophageal squamous cell carcinoma and precancerous lesions

“…When the lesion area is large enough, the artificial esophageal ulcer causes excess absence of epithelial cells and results in fibrous repair in the submucosa[ 27 ], which is the primary cause of esophageal stricture. To prevent esophageal stricture, the administration of steroids is useful, as previously reported[ 28 , 29 ], while endoscopic balloon dilation and esophageal stent implantation can also be options[ 30 , 31 ]. For positive margin, previous studies reported its incidence after ESD to be 3%-17%[ 18 , 32 , 33 ].…”

Endoscopic management of Barrett's esophagus: Western perspective of current status and future prospects

“…To reduce this risk, high-risk patients may benefit from post-procedure steroid injection or oral corticosteroid therapy. 68,69 Ablative therapies, especially RFA, can also pose risks to the development of strictures. After EMR, ESD and ablative treatment, patients should receive high-dose proton pump therapy to mitigate stricture formation, following evidence of its use in reflux esophagitis.…”

“…In situations where the EMR or ESD dissection circumference is >75% or craniocaudal resection length over 40 mm, the risk of developing a symptomatic stricture is up to 50%. To reduce this risk, high‐risk patients may benefit from post‐procedure steroid injection or oral corticosteroid therapy 68,69 . Ablative therapies, especially RFA, can also pose risks to the development of strictures.…”