Cicatricial stenosis after endoscopic submucosal dissection of esophageal cancer effectively treated with a temporary self-expandable metal stent

Prevention of esophageal stricture after endoscopic resection

Stricture formation after esophageal endoscopic resection has a negative impact on patients' quality of life because it causes dysphagia and requires multiple endoscopic dilations. Various methods by which to prevent stricture have recently been developed and reported. Among these methods, local steroid injection is the most commonly used and is currently considered the standard method for noncircumferential resection. However, local steroid injection has a limited effect on circumferential resection. Thus, oral steroid administration is used for such cases because it may have a stronger effect than local injection. Steroid treatment, both by local injection and oral administration, is effective and low-cost; however, it may cause fragility of the esophageal wall, resulting in adverse events such as perforation during balloon dilatation. Many innovative approaches have been developed, such as tissue-shielding methods with polyglycolic acid, tissue engineering approaches with autologous oral mucosal epithelial cell sheet transplantation, and stent insertion. These methods may be promising, but they are limited by a scarcity of data. Further investigations are needed to confirm the efficacy of these methods.

Progress on the Prevention of Esophageal Stricture after Endoscopic Submucosal Dissection

Endoscopic submucosal dissection (ESD) has been widely accepted as an effective, minimally invasive treatment for superficial esophageal cancers. However, esophageal stricture often occurs in patients with large mucosal defects after ESD. In this review, we discuss various approaches recently researched to prevent esophageal strictures after ESD. These approaches can be classified as pharmacological treatments, esophageal stent treatments, and tissue engineering approaches. Most of the preventive approaches still have their limitations and require further research. With the improvement of current therapies, ESD can be more widely utilized as a minimally invasive treatment with minimal complications.

Endoscopic Submucosal Dissection for Superficial Proximal Esophageal Neoplasia is Highly Successful

OBJECTIVE

The aim of this study was to evaluate the outcomes of endoscopic submucosal dissection (ESD) for superficial proximal esophageal neoplasia.

SUMMARY OF BACKGROUND DATA

The surgery for a tumor located in proximal esophagus is relatively difficult and leads to a high morbidity and mortality. ESD is a minimally invasive endoscopic treatment of superficial neoplasia of the gastrointestinal tract allowing en block resection with low recurrence rates; however, ESD for superficial proximal esophageal neoplasia is little known.

METHODS

We retrospectively analyzed 102 consecutive patients who fit the inclusion criteria with 106 lesions who underwent ESD from February 2009 to July 2015 at the Zhongshan Hospital, Fudan University in Shanghai, China. During the study, the en bloc and pathologically complete resection rates, complication rate, incidence of esophageal stricture after ESD, disease-specific, and overall survival rates were evaluated.

RESULTS

The mean age was 62 (45-84) years with 100% en bloc resection rate. The mean operation time was 48 (10-144) minutes. The mean diameter of the resected tumors was 2.9 (1.2-6.5) cm. The pathological diagnoses were high-grade intraepithelial dysplasia in 45 (42.5%) lesions, and the rest were squamous cell carcinoma with staging of intraepithelial in 18 (17.0%), lamina propria in 13 (12.3%), muscularis mucosa in 16 (15.1%), SM1 in 10 (9.4%), and SM2 or deeper in 4 (3.8%) of the lesions. The R0 resection rates were 94.3% (100/106). There was no delayed bleeding. Two small perforations observed were closed successfully with clips. Symptomatic esophageal strictures in 17 (16.7%) patients were treated by endoscopic balloon dilation with a mean of 4 (1-14) times and 88.2% (15/17) success. Additional treatments of esophagectomy or chemoradiotherapy were recommended to patients with SM1 or deeper neoplasia or incomplete resection. Local recurrence was observed in 3 (2.9%) cases. Fifteen patients were lost to follow-up. Five-year overall survival rate was 98% and disease-specific survival rate was 100%. The mean follow-up time was 33.6 months.

CONCLUSIONS

ESD for the superficial proximal esophageal neoplasia is a safe and a very effective treatment method with a 100% 5-year disease-specific survival rate.

Esophageal stricture after endoscopic submucosal dissection treated successfully by temporary stent placement

The growing use of endoscopic submucosal dissection (ESD) has enabled the highly curative treatment of early esophageal cancer. The circumferential extent of the tumor is reportedly related to the frequency of post-treatment stricture, with postoperative esophageal stricture reported to occur frequently when the post-resection mucosal defect exceeds 75 % of the esophageal luminal circumference. In some clinical cases, locally injected or orally administered steroids aimed at preventing post-treatment stricture fail to prevent re-stricture. Only two prior reports have investigated temporary stent placement for stricture after ESD for early esophageal cancer, and consensus is lacking on the appropriate duration and timing of stent placement. Here, we report our experience with a case of stricture after ESD for early esophageal cancer, in which temporary stent placement was effective for releasing the stricture for at least 6 months.

Prevention of Esophageal Stricture After Endoscopic Submucosal Dissection: A Systematic Review

BACKGROUND

Endoscopic submucosal dissection (ESD) is rapidly becoming a favored method for removing early esophageal cancer, but the residual defects can be complicated with strictures that require repeated endoscopic balloon dilatation. Measures for preventing the post-ESD strictures have been sought. We conducted a systematic review of recent studies to evaluate these methods.

METHODS

We searched MEDLINE, Cochrane Central Register of Controlled Trials, Embase, and Google Scholar until November 30, 2014. Included studies were prospective and retrospective one- and two-arm studies. All studies had to include at least on preventive method for post-ESD stricture. Thirteen studies were included in the review.

RESULTS

Among the studies that used corticosteroids to prevent post-ESD stricture, we found that (1) injection of triamcinolone acetonide into the esophageal lesion resulted in a substantial reduction in the rate of stricture, and (2) the use of oral prednisolone was associated with a significantly reduced rate of dilatation sessions and stricture. Studies of other preventative measures included more recently developed scaffold-based and cell-based tissue-engineering approaches which seem very promising but require additional rigorously controlled studies to test their effectiveness.

CONCLUSIONS

Until a safer and more effective method is developed, our review supports the use of corticosteroids, either through injection or oral route, together with endoscopic dilatation in prevention of post-ESD strictures.

Locoregional steroid injection prevents stricture formation after endoscopic submucosal dissection for esophageal cancer: a propensity score matching analysis

BACKGROUND

Although endoscopic submucosal dissection (ESD) has become accepted for the treatment of superficial esophageal cancer, the incidence of stricture formation caused by ESD for widespread lesions is high and leads to a low quality of life. A few studies reported that locoregional steroid injections are useful for the prevention of such stricture formation compared with historical controls. We evaluated the efficacy of prophylactic locoregional steroid injections for stricture formation caused by ESD using quasi-randomized analysis.

METHODS

This matched case-control study included 461 superficial esophageal cancers from 305 patients who underwent ESD between 2006 and 2013. We used two methods of locoregional steroid injection to prevent stricture formation after ESD. A propensity score matching analysis was performed to reduce the effects of a selection bias for steroid injections and other potential confounding factors. In addition, generalized estimating equations were used to analyze repeated measures data. We compared the incidence of stricture formation with or without steroid injections.

RESULTS

Forty-two lesions were treated with locoregional steroid injection (dexamethasone/triamcinolone, 23/19) after ESD and esophageal stricture formation occurred in 36 lesions. Fifty-six lesions treated with or without steroid injections were matched after propensity score matching. Locoregional steroid injection reduced the incidence of stricture formation to 10.7% (3/28) of patients compared with 35.7% (10/28) in the control group (odds ratio 4.63, 95% confidence interval 1.11-19.25, p = 0.035).

CONCLUSIONS

Locoregional steroid injections could be efficient for the prevention of stricture formation after ESD for superficial esophageal cancer.

Useful strategies to prevent severe stricture after endoscopic submucosal dissection for superficial esophageal neoplasm

The minimal invasiveness of endoscopic submucosal dissection (ESD) prompted us to apply this technique to large-size early esophageal squamous cell carcinoma and Barrett’s adenocarcinoma, despite the limitations in the study population and surveillance duration. A post-ESD ulceration of greater than three-fourths of esophageal circumference was advocated as an important risk factor for refractory strictures that require several sessions of dilation therapy. Most of the preoperative conditions are asymptomatic, but dilatation treatment for dysphagia associated with the stricture has potential risks of severe complications and a worsening of quality of life. Possible mechanisms of dysphasia were demonstrated based on dysmotility and pathological abnormalities at the site: (1) delayed mucosal healing; (2) severe inflammation and disorganized fibrosis with abundant extracellular matrices in the submucosa; and (3) atrophy in the muscularis proper. However, reports on the administration of anti-scarring agents, preventive dilation therapies, and regenerative medicine demonstrated limited success in stricture prevention, and there were discrepancies in the study designs and protocols of these reports. The development and consequent long-term assessments of new prophylactic technologies on the promotion of wound healing and control of the inflammatory/tumor microenvironment will require collaboration among various research fields because of the limited accuracy of preoperative staging and high-risk of local recurrence.

Prevention and treatment of esophageal stenosis after endoscopic submucosal dissection for early esophageal cancer

Endoscopic submucosal dissection (ESD) for the treatment of esophageal mucosal lesions is associated with a risk of esophageal stenosis, especially for near-circumferential or circumferential esophageal mucosal defects. Here, we review historic and modern studies on the prevention and treatment of esophageal stenosis after ESD. These methods include prevention via pharmacological treatment, endoscopic autologous cell transplantation, endoscopic esophageal dilatation, and stent placement. This short review will focus on direct prevention and treatment, which may help guide the way forward.

Preventing stricture formation by covered esophageal stent placement after endoscopic submucosal dissection for early esophageal cancer

OBJECTIVE

We aimed to evaluate the efficacy and safety of fully covered esophageal stent placement for preventing esophageal strictures after endoscopic submucosal dissection (ESD).

METHODS

Twenty-two patients with a mucosal defects that exceeded 75 % of the circumference of the esophagus after ESD treatment for superficial esophageal squamous cell carcinomas were grouped according to the type of mucosal defect and randomized to undergo fully covered esophageal stent placement post-ESD (group A, n = 11) or no stent placement (group B, n = 11). In group A, the esophageal stents were removed 8 weeks post-ESD. Endoscopy was performed when patients reported dysphagia symptoms and at 12 weeks post-ESD in patients without symptoms. Savary-Gilliard dilators were used for bougie dilation in patients experiencing esophageal stricture in both groups, and we compared the rates of post-ESD strictures and the need for bougie dilation procedures.

RESULTS

The proportion of patients who developed a stricture was significantly lower in group A (18.2 %, n = 2) than in group B (72.7 %, n = 8) (P < 0.05). Moreover, the number of bougie dilation procedures was significantly lower in group A (mean 0.45, range 0-3) than in group B (mean 3.9, range 0-17) (P < 0.05). The two patients in group A who experienced stricture also had stent displacement.

CONCLUSIONS

Esophageal stents are a safe and effective method of preventing esophageal strictures in cases where >75 % of the circumference of the esophagus has mucosal defects after ESD treatment for early esophageal cancer.

[Endoscopic submucosal dissection: only for expert endoscopists?]

Endoscopic submucosal dissection (ESD) can be applied to early gastrointestinal cancers. This technique was developed to achieve radical curative resection and to reduce unnecessary surgical interventions. ESD was designed in eastern countries and is not widely used in the West. Although ESD represents a major therapeutic advance in endoscopy and is performed with curative intent, the complication rate (hemorrhage, perforation) is higher than reported in other techniques, requiring from endoscopists the acquirement of technical skill and experience through a structured and progressive training program to reduce the morbidity associated with this technique and increase its potential benefits. Although there is substantial published evidence on the applications and results of ESD, there are few publications on training in this technique and a standardized training program is lacking. The current article aims to describe the various proposals for training, as well as the basic principles of the technique, its indications, and the results obtained, since theoretical knowledge that would guide endoscopists during the clinical application of ESD is advisable before training begins. Training in an endoscopic technique has a little value without knowledge of the technique's aims, the situations in which it should be applied, and the results that can be expected.