Utility of radial incision and cutting with steroid injection for refractory stricture after endoscopic submucosal dissection for large superficial esophageal squamous cell carcinoma

Endoscopic balloon dilation with steroid injection versus radial incision and cutting with steroid injection for refractory esophageal anastomotic stricture: a randomized study

Esophageal stricture causes severe distress to patients; however, there are no established treatments for esophageal anastomotic strictures refractory to endoscopic balloon dilation (EBD). Steroid injection added to EBD and radial incision and cutting (RIC) are effective for such strictures, but it is unclear which is more effective. The objective of this study was to investigate the safety and efficacy of RIC plus steroid injection compared with EBD plus steroid injection for patients with refractory anastomotic strictures after esophagectomy.This was a multicenter, randomized phase II/III trial. Patients with esophageal anastomotic strictures refractory to three or more dilations were eligible. The primary endpoint in phase II was the proportion of predefined grade 3/4 adverse events (AEs). The co-primary endpoints in phase III were restricture-free survival and number of EBDs in the 24 weeks after treatment.130 patients were enrolled, with a dysphagia score of grade 2 in 104 patients (80.0%). The median number of dilations before registration was five in each arm. Predefined grade 3/4 AEs occurred in two patients (3.1%) in each arm. Restricture-free survival was 10.6 weeks (95%CI 6.9-20.1 weeks) with EBD and 8.7 weeks (95%CI 7.1-10.9 weeks) with RIC (one-sided P=0.82). The median number of EBDs in the 24 weeks after initial treatment was one (interquartile range [IQR] 0-2) for EBD and two (IQR 0-3) for RIC (one-sided P=0.99).EBD combined with steroid injection is the standard treatment for refractory anastomotic stricture after esophagectomy.

Utility of modified endoscopic radial incision and selective cutting combined with short-term stenting for refractory stricture in patients undergoing endoscopic submucosal dissection of superficial esophageal carcinoma

BACKGROUND

Refractory esophageal stricture is the common complication of extensive endoscopic submucosal dissection (ESD), without satisfactory endoscopic treatment strategies. We evaluated the efficacy, safety, and long-term patency of the modified endoscopic radial incision and selective cutting combined with short-term stenting (RISC-STS) for the treatment of refractory esophageal stenosis.

METHODS

This was a retrospective study. Patients diagnosed with refractory esophageal stricture from June 2016 to June 2023 were enrolled. Efficacy, safety, and risk factors for dysphagia after RISC-STS operation were assessed.

RESULTS

Compared with clinical symptoms before RISC-STS, there was no significant improvement in the times of stricture recurred (p = 0.75). However, the narrowest diameter of esophageal stenosis was significantly larger after RISC-STS treatment (p = 0.04). Corresponding dysphagia scores after RISC-STS were obviously lowered according to the Mellow-Pinkas grading scale (p = 0.002). More cases ((14 (60.87%) vs 5 (21.74%)) received valid symptom-relief periods after RISC-STS (p = 0.0004). The complications of RISC-STS include perforation (4.35%), fever (4.35%), and pain (30.43%). Univariate Cox analysis suggested that resection length >7 cm of scar tissue was a risk factor for refractory dysphagia after RISC-STS.

CONCLUSION

The present study revealed that RISC-STS is an effective and safe technique for refractory esophageal stricture with lower restenosis, higher valid symptom-relief rate, and fewer complications.

Endoscopic incisional therapy for benign anastomotic strictures after esophagectomy or gastrectomy: a systematic review and meta-analysis

BACKGROUND

Studies have evaluated the efficacy of endoscopic incisional therapy (EIT) for benign anastomotic strictures. We performed a systematic review and meta-analysis to evaluate stricture recurrence after EIT following esophagectomy or gastrectomy.

METHODS

A systematic search of databases was performed up to April 2nd, 2023, after selection of key search terms with the research team. Inclusion criteria included human participants undergoing EIT for a benign anastomotic stricture after esophagectomy or gastrectomy, age ≥ 18, and n ≥ 5. Our primary outcome was the incidence of stricture recurrence among patients treated with EIT compared to dilation. Our secondary outcome was the stricture-free duration after EIT and rate of adverse events. Meta-analysis was performed with RevMan 5.4.1 using a Mantel-Haenszel random-effects model. Publication bias was evaluated with funnel plots and the Egger test.

RESULTS

A total of 2550 unique preliminary studies underwent screening of abstracts and titles. This led to 33 studies which underwent full-text review and five studies met the inclusion criteria. Meta-analysis revealed reduced odds of overall stricture recurrence (OR 0.35, 95% CI 0.13-0.92, p = 0.03; I2 = 71%) and reduced odds of stricture recurrence among naïve strictures (OR 0.32, 95% CI 0.17-0.59, p = 0.0003; I2 = 0%) for patients undergoing EIT compared to dilation. There was no significant difference in the odds of stricture recurrence among recurrent strictures (OR 0.63, 95% CI 0.12-3.28, p = 0.58; I2 = 81%). Meta-analysis revealed a significant increase in the recurrence-free duration (MD 42.76, 95% CI 12.41-73.11, p = 0.006) among patients undergoing EIT compared to dilation.

CONCLUSION

Current data suggest EIT is associated with reduced odds of stricture recurrence among naïve anastomotic strictures. Large, prospective studies are needed to characterize the safety profile of EIT, address publication bias, and to explore multimodal therapies for refractory strictures.

Predictive factors for esophageal stenosis in patients receiving prophylactic steroid therapy after endoscopic submucosal dissection for esophageal squamous cell carcinoma

BACKGROUND

Methods to prevent esophageal stenosis (ES) after endoscopic submucosal dissection (ESD) for superficial esophageal squamous cell carcinoma (ESCC) have received increasing attention. Although steroid administration is a prophylactic treatment, the risk factors for ES during prophylactic steroid therapy remain unknown. Therefore, this study aimed to retrospectively evaluate the risk factors for refractory ES in patients administered prophylactic steroids after ESD for ESCC.

METHODS

Among 795 patients with ESCC (854 lesions), 180 patients (211 lesions) administered local triamcinolone acetonide (TrA) and/or oral prednisolone were recruited for this study. We compared the total number of endoscopic balloon dilatation (EBD) procedures performed for post-ESD ES and clinical findings (tumor size, ESD history or chemoradiation therapy [CRT], entire circumferential resection, muscle layer damage, supplemental oral prednisolone administration, EBD with TrA injection, and additional CRT) between patients with refractory and non-refractory ES. EBD was continued until dysphagia resolved. We categorized cases requiring ≥ 8 EBD procedures as refractory postoperative stenosis and divided the lesions into two groups.

RESULTS

Multivariate logistic regression analysis revealed that factors such as ESD history, CRT history, tumor size, and entire circumferential resection were independently associated with the development of refractory ES. The withdrawal rates of EBD at 3 years were 96.1% (52/53) and 58.5% (39/59) in the non-refractory and refractory groups, respectively.

CONCLUSIONS

Our data suggest that entire circumferential resection and CRT history are risk factors for refractory post-ESD ES in ESCC, even with prophylactic steroid administration.

Repeated steroid injection and polyglycolic acid shielding for prevention of refractory esophageal stricture

BACKGROUND

Postoperative stricture and refractory stricture are severe adverse events which occur after expansive esophageal endoscopic submucosal dissection (ESD). The aim of this study was to assess the efficacy of steroid injection, polyglycolic acid (PGA) shielding, and of additional steroid injection thereafter for the prevention of refractory esophageal stricture.

METHODS

This is a retrospective cohort study of 816 consecutive cases of esophageal ESD performed between 2002 and 2021 at the University of Tokyo Hospital. After 2013, all patients with a diagnosis of superficial esophageal carcinoma covering over 1/2 the esophageal circumference underwent preventive treatment immediately after ESD with either "PGA shielding", "steroid injection", or "steroid injection + PGA shielding". Additional steroid injection was performed for high-risk patients after 2019.

RESULTS

The risk of refractory stricture was especially high in the cervical esophagus (OR 24.77, p = 0.002) and after total circumferential resection (OR 894.04, p < 0.001). "Steroid injection + PGA shielding" was the only method significantly effective in preventing stricture occurrence (OR 0.36; 95% CI 0.15-0.83, p = 0.012). This method also decreased the risk of refractory stricture (OR 0.38; 95% CI 0.10-1.28, p = 0.096), but additional steroid injection was the only significantly effective method for prevention of refractory stricture (OR 0.42; 95% CI 0.14-0.98, p = 0.029).

CONCLUSION

Combining steroid injection and PGA shielding is effective for preventing post-ESD stricture and refractory stricture. Additional steroid injection is a viable option for patients at high-risk for refractory stricture.

Endoscopic radial incision versus endoscopic balloon dilation as initial treatments of benign esophageal anastomotic stricture

BACKGROUND AND AIM

We aim to evaluate the efficacy and safety of endoscopic radial incision (ERI) versus endoscopic balloon dilation (EBD) treatment of naïve, recurrent, and refractory benign esophageal anastomotic strictures.

METHODS

One hundred and one ERI, 145 EBD, and 42 ERI combined with EBD sessions were performed in 136 consecutive patients with benign esophageal anastomotic stricture after esophagectomy at Zhongshan Hospital from January 2016 to August 2021. Baseline characteristics, operational procedures, and clinical outcomes data were retrospectively evaluated. Parameters and recurrence-free survival (RFS) were compared between ERI and EBD in patients with naïve or recurrent or refractory strictures. Risk factors for re-stricture after ERI were identified using univariate and multivariate analyses.

RESULTS

Twenty-nine ERI versus 68 EBD sessions were performed for naïve stricture, 26 ERI versus 60 EBD for recurrent strictures, and 46 ERI versus 17 EBD for refractory stricture. With comparable baseline characteristics, RFS was greater in the ERI than the EBD group for naïve strictures (P = 0.0449). The ERI group had a lower 12-month re-stricture rate than the EBD group (37.9% vs 61.8%, P = 0.0309) and a more prolonged patency time (181.5 ± 263.1 vs 74.5 ± 82.0, P = 0.0233). Between the two interventions, recurrent and refractory strictures had similar RFS (P = 0.0598; P = 0.7668). Multivariate analysis revealed initial ERI treatment was an independent predictive factor for lower re-stricture risk after ERI intervention (odds ratio = 0.047, P = 0.001). Few adverse events were observed after ERI or EBD (3.0% vs 2.1%, P = 0.6918).

CONCLUSIONS

ERI is associated with lower re-stricture rates with better patency and RFS compared with EBD for naive strictures.

Advances in the application of regenerative medicine in prevention of post-endoscopic submucosal dissection for esophageal stenosis

Endoscopic submucosal dissection (ESD) is a curative treatment for superficial esophageal cancer with distinct advantages. However, esophageal stenosis after ESD remains a tough problem, especially after large circumferential proportion of esophageal mucosa is removed, which limits the wide use of ESD, especially in circumferential lesions. In this scenario, preventive procedures are highly recommended against post-ESD esophageal stenosis. However, the efficacy and safety of traditional prophylactic methods (steroids, metal and biodegradable stents, balloon dilation, radial incision, etc.) are not satisfactory and novel strategies need to be developed. Regenerative medicine has been showing enormous potential in the reconstruction of organs including the esophagus. In this review, we aimed to describe the current status of regenerative medicine in prevention of post-ESD esophageal stenosis. Cell injection, cell sheet transplantation, and extracellular matrix implantation have been proved effective. However, numerous obstacles still exist and further studies are necessary.