Management of esophageal stricture after complete circular endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma - PubMed (original) (raw)

Management of esophageal stricture after complete circular endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma

Hajime Isomoto et al. BMC Gastroenterol. 2011.

Abstract

Background: Endoscopic submucosal dissection (ESD) permits removal of esophageal epithelial neoplasms en bloc, but is associated with esophageal stenosis, particularly when ESD involves the entire circumference of the esophageal lumen. We examined the effectiveness of systemic steroid administration for control of postprocedural esophageal stricture after complete circular ESD.

Methods: Seven patients who underwent wholly circumferential ESD for superficially extended esophageal squamous cell carcinoma were enrolled in this study. In 3 patients, prophylactic endoscopic balloon dilatation (EBD) was started on the third post-ESD day and was performed twice a week for 8 weeks. In 4 patients, oral prednisolone was started with 30 mg daily on the third post-ESD day, tapered gradually (daily 30, 30, 25, 25, 20, 15, 10, 5 mg for 7 days each), and then discontinued at 8 weeks. EBD was used as needed whenever patients complained of dysphagia.

Results: En bloc ESD with tumor-free margins was safely achieved in all cases. Patients in the prophylactic EBD group required a mean of 32.7 EBD sessions; the postprocedural stricture was dilated up to 18 mm in diameter in these patients. On the other hand, systemic steroid administration substantially reduced or eliminated the need for EBD. Corticosteroid therapy was not associated with any adverse events. Post-ESD esophageal stricture after complete circular ESD was persistent, requiring multiple EBD sessions.

Conclusions: Use of oral prednisolone administration may be an effective treatment strategy for reducing post-ESD esophageal stricture after complete circular ESD.

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Figures

Figure 1

Figure 1

In Case 3, complete circular endoscopic submucosal dissection (ESD) was achieved, and endoscopic balloon dilatation (EBD) was performed preemptively. Nevertheless, he required total 48 sessions to relieve his dysphagia. A. Chromoendoscopy with an iodine solution reveals the iodine-unstained area spreading to involve nearly the entire circumference of the esophagus (Case 3, Table 1). Wholly circumferential ESD was performed. B. Artificial ulcer immediately after complete circular resection. C. The tumor was removed en bloc with tumor-free lateral and basal margins, and histopathological assessment revealed intramucosal invasive squamous cell carcinoma (m2). Repeat esophagoscopy revealed persistent esophageal stricture (D) despite 16 sessions (twice a week, for 8 weeks) of EBD (E), which was started on the third postoperative day. Temporary improvement of the stricture was achieved with EBD (F), but this patient required 48 EBD sessions.

Figure 2

Figure 2

In Case 5, complete circular ESD was achieved, and oral prednisolone was given. He has not required any EBD sessions without no postprocedural stricture and the related dysphagia. A. Chromoendoscopy with iodine staining revealed a discolored area spreading to involve nearly the entire circumference of the esophagus in the middle thoracic esophagus (Case 5, Table 1), and wholly circumferential, endoscopic submucosal dissection was performed. B. Artificial ulcer immediately after complete circular resection. Complete circular resection was achieved (C), and the tumor was removed en bloc with tumor-free lateral and basal margins (D). Histopathological assessment revealed intramucosal invasive squamous cell carcinoma (m2). Oral prednisolone (30 mg) was initiated on the third postoperative day, tapered, and then discontinued 8 weeks later. E. Follow-up endoscopy 6 months later revealed no postprocedural stricture without EBD.

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