Introduction
Endoscopic submucosal dissection (ESD) is the standard treatment for superficial esophageal cancer. Previous studies have indicated that patients with a circumferential mucosal defect of ≥3/4 post-ESD are at a significantly increased risk of developing postoperative esophageal stricture. Previous research suggests that the incidence of esophageal stricture can be reduced by either endoscopic injection or oral administration of corticosteroids. However, the effectiveness of combined endoscopic injection and oral corticosteroids in preventing post-circumferential ESD esophageal stricture has not been fully analyzed.
Aims & Methods
This retrospective study included patients who underwent circumferential esophageal ESD with a mucosal defect of ≥3/4 at West China Hospital, Sichuan University, from January 2014 to August 2023. Patients were divided into two groups based on whether they received corticosteroids to prevent esophageal stricture: the steroid group and the non-steroid group. The steroid group received multiple uniform injections of 80 mg triamcinolone acetonide directly into the esophageal lesion immediately after ESD and started oral prednisolone on the third day post-operation, continuing for eight weeks; the non-steroid group did not receive corticosteroid prevention. The main outcomes measured were the incidence and timing of stricture formation.
Results
A total of 221 patients were included in the study, with 150 in the steroid group and 71 in the non-steroid group. The incidence of post-ESD esophageal stricture was 43.33% (65/150) in the steroid group and 47.89% (34/71) in the non-steroid group, with no significant difference (P=0.564).
However, in patients with a full circumferential mucosal defect (100%), the incidence of stricture was 100% (16/16) in the non-steroid group and 76.67% (46/60) in the steroid group, a difference that was statistically significant (P=0.032). For patients with a defect of 3/4 to 1, the incidence was 32.73% (18/55) in the non-steroid group and 21.11% (19/90) in the steroid group, with no significant difference (P=0.120).
In follow-up analysis, the median time to stricture occurrence was 9 weeks (range 1.29-82.43 weeks), with median times of 9.86 weeks (range 3.71-82.43 weeks) in the steroid group and 5.27 weeks (range 1.29-49 weeks) in the non-steroid group, a statistically significant difference (P<0.001). For patients with a full circumferential mucosal defect, the median time to stricture occurrence was 8.5 weeks (range 1.29-49 weeks), while for patients with a defect of 3/4 to <1, the median time was 9.14 weeks (range 4.57-82.43 weeks), with no significant difference between these groups (P=0.390).
Conclusion
Overall, while endoscopic injection combined with oral corticosteroids does not significantly reduce the overall risk of post-circumferential ESD esophageal stricture, it can effectively extend the time to stricture occurrence. Particularly, patients with a full circumferential ESD benefit significantly from this treatment strategy, showing a reduced incidence of postoperative esophageal stricture, suggesting that such patients may benefit more from the combined use of endoscopic injection and oral corticosteroids.
References
1. Libânio D, Pimentel-Nunes P, Bastiaansen B, et al. Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy. 2023;55(4):361-389. doi:10.1055/a-2031-0874
2. Sami SS, Haboubi HN, Ang Y, et al. UK guidelines on oesophageal dilatation in clinical practice. Gut. 2018;67(6):1000-1023. doi:10.1136/gutjnl-2017-315414
3. Ishihara R, Arima M, Iizuka T, et al. Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer. Dig Endosc. 2020;32(4):452-493. doi:10.1111/den.13654
