Refractory strictures despite steroid injection after esophageal endoscopic resection

Abstract

Background: Although steroid injection prevents stricture after esophageal endoscopic submucosal dissection (ESD), some patients require repeated sessions of endoscopic balloon dilation (EBD). We investigated the risk for refractory stricture despite the administration of steroid injections to prevent stricture in patients undergoing esophageal ESD. Refractory stricture was defined as the requirement for more than three sessions of EBD to resolve the stricture. In addition, the safety of steroid injections was assessed based on the rate of complications. Patients and methods: We analyzed data from 127 consecutive patients who underwent esophageal ESD and had mucosal defects with a circumferential extent greater than three-quarters of the esophagus. To prevent stricture, steroid injection was performed. EBD was performed whenever a patient had symptoms of dysphagia. Results: The percentage of patients with a tumor circumferential extent greater than 75 % was significantly higher in those with refractory stricture than in those without stricture (P = 0.001). Multivariate analysis adjusted for age, sex, history of radiation therapy, tumor location, and tumor diameter showed that a tumor circumferential extent greater than 75 % was an independent risk factor for refractory stricture (adjusted odds ratio [OR] 5.49 [95 %CI 1.91 – 15.84], P = 0.002). Major adverse events occurred in 3 patients (2.4 %): perforation during EBD in 2 patients and delayed perforation after EBD in 1 patient. The patient with delayed perforation underwent esophagectomy because of mediastinitis. Conclusions: A tumor circumferential extent greater than 75 % is an independent risk factor for refractory stricture despite steroid injections. The development of more extensive interventions is warranted to prevent refractory stricture.

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

“…We use relatively low doses over a limited period and it seems unlikely that this has an impact in the long term. Moreover, the stricture rate increases drastically when 75% of the circumference is involved [20] and in our study 24/31 patients underwent circumferential resection in 2 to 3 sessions (Table 1). The other patients (7/31) underwent resection in 1 session of esophageal mucosa larger than the half-circumference, but less than 75% of the esophageal lumen (Table 1).…”

Prevention of esophageal stricture after endoscopic resection

“…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.…”

“…In one clinical study, a deep submucosal tear without perforation occurred when the endoscope was passed through the narrow space formed by the post‐ESD scar in a patient who received local TA injection . Other authors have reported a higher risk of perforation in balloon dilation among patients undergoing steroid treatment . Careful balloon dilatation, such as that using a small‐caliber balloon or low inflation pressure, is advised after steroid treatment.…”

“…Previous reports indicate that after whole circumferential resection, oral steroid administration may be a preferred treatment method because local TA injection failed to prevent stricture (Table ). Combination treatment involving oral steroid administration and local TA injection is also being evaluated at some facilities .…”

“…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.…”