Advertisement

Steroid injection and polyglycolic acid shielding to prevent stricture after esophageal endoscopic submucosal dissection: a retrospective comparative analysis (with video)

      Background and Aims

      Postoperative stricture after expansive esophageal endoscopic submucosal dissection (ESD) is a severe adverse event. Previous single-arm reports have suggested that polyglycolic acid (PGA) shielding may prevent stricture. This study was performed to assess the efficacy of this method through a comparative analysis.

      Methods

      This is a retrospective analysis of 500 consecutive cases of esophageal ESD performed between 2002 and 2018 at the University of Tokyo Hospital. After 2013, patients with a diagnosis of superficial esophageal carcinoma covering more than half of the esophageal circumference underwent preventive treatment with either PGA shielding or steroid injection + PGA shielding after ESD. The efficacy of these methods for preventing post-ESD stricture was assessed through multivariable logistic regression analysis.

      Results

      The risk of postoperative stricture was especially high in the cervical esophagus (odds ratio [OR], 4.60; 95% confidence interval [CI], 0.65-61.09) and after total circumferential resection (OR, 3.58×103; lower bound of 95% CI, >185). Steroid injection + PGA shielding was the only method significantly effective in preventing stricture (OR, 0.30; 95% CI, 0.10-0.78; P = .009). In the relatively low-risk subgroup (excluding cervical esophageal cancer and complete circumferential resection), the postoperative stricture rates for steroid injection + PGA shielding versus PGA shielding versus control were 18.9% versus 41.4% versus 51.7%, respectively (P = .015). However, the efficacy of this was limited in extremely high-risk cases.

      Conclusion

      The combination of steroid injection and PGA shielding is effective for preventing post-ESD stricture. There is a need for even more effective methods for cervical esophageal cancer and complete circumferential resection.

      Graphical abstract

      Abbreviations:

      CI (confidence interval), EBD (endoscopic balloon dilation), ESD (endoscopic submucosal dissection), OR (odds ratio), PGA (polyglycolic acid)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Cao Y.
        • Liao C.
        • Tan A.
        • et al.
        Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract.
        Endoscopy. 2009; 41: 751-757
        • Fujishiro M.
        • Kodashima S.
        • Goto O.
        • et al.
        Endoscopic submucosal dissection for esophageal squamous cell neoplasms.
        Dig Endosc. 2009; 21: 109-115
        • Takahashi H.
        • Arimura Y.
        • Masao H.
        • et al.
        Endoscopic submucosal dissection is superior to conventional endoscopic resection as a curative treatment for early squamous cell carcinoma of the esophagus (with video).
        Gastrointest Endosc. 2010; 72 (2): 255-264 e1
        • Kuwano H.
        • Nishimura Y.
        • Oyama T.
        • et al.
        Guidelines for Diagnosis and Treatment of Carcinoma of the Esophagus April 2012 edited by the Japan Esophageal Society.
        Esophagus. 2015; 12: 1-30
        • Pimentel-Nunes P.
        • Dinis-Ribeiro M.
        • Ponchon T.
        • et al.
        Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) guideline.
        Endoscopy. 2015; 47: 829-854
        • Ono S.
        • Fujishiro M.
        • Niimi K.
        • et al.
        Predictors of postoperative stricture after esophageal endoscopic submucosal dissection for superficial squamous cell neoplasms.
        Endoscopy. 2009; 41: 661-665
        • Chen M.
        • Dang Y.
        • Ding C.
        • et al.
        Lesion size and circumferential range identified as independent risk factors for esophageal stricture after endoscopic submucosal dissection.
        Surg Endosc. 2020; 34: 4065-4071
        • Ono S.
        • Fujishiro M.
        • Niimi K.
        • et al.
        Long-term outcomes of endoscopic submucosal dissection for superficial esophageal squamous cell neoplasms.
        Gastrointest Endosc. 2009; 70: 860-866
        • Iizuka T.
        • Kikuchi D.
        • Hoteya S.
        • et al.
        Efficacy and safety of endoscopic submucosal dissection for superficial cancer of the cervical esophagus.
        Endosc Int Open. 2017; 5: E736-E741
        • Ariyoshi R.
        • Toyonaga T.
        • Tanaka S.
        • et al.
        Clinical outcomes of endoscopic submucosal dissection for superficial esophageal neoplasms extending to the cervical esophagus.
        Endoscopy. 2018; 50: 613-617
        • Isomoto H.
        • Yamaguchi N.
        • Nakayama T.
        • et al.
        Management of esophageal stricture after complete circular endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma.
        BMC Gastroenterol. 2011; 11: 46
        • Sato H.
        • Inoue H.
        • Kobayashi Y.
        • et al.
        Control of severe strictures after circumferential endoscopic submucosal dissection for esophageal carcinoma: oral steroid therapy with balloon dilation or balloon dilation alone.
        Gastrointest Endosc. 2013; 78: 250-257
        • Takahashi H.
        • Arimura Y.
        • Okahara S.
        • et al.
        A randomized controlled trial of endoscopic steroid injection for prophylaxis of esophageal stenoses after extensive endoscopic submucosal dissection.
        BMC Gastroenterol. 2015; 15: 1
        • Yamaguchi N.
        • Isomoto H.
        • Nakayama T.
        • et al.
        Usefulness of oral prednisolone in the treatment of esophageal stricture after endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma.
        Gastrointest Endosc. 2011; 73: 1115-1121
        • Hashimoto S.
        • Kobayashi M.
        • Takeuchi M.
        • et al.
        The efficacy of endoscopic triamcinolone injection for the prevention of esophageal stricture after endoscopic submucosal dissection.
        Gastrointest Endosc. 2011; 74: 1389-1393
        • Hanaoka N.
        • Ishihara R.
        • Takeuchi Y.
        • et al.
        Intralesional steroid injection to prevent stricture after endoscopic submucosal dissection for esophageal cancer: a controlled prospective study.
        Endoscopy. 2012; 44: 1007-1011
        • Ohki T.
        • Yamato M.
        • Ota M.
        • et al
        Prevention of esophageal stricture after endoscopic submucosal dissection using tissue-engineered cell sheets.
        Gastroenterology. 2012; 143 (e1-2): 582
        • Sakaguchi Y.
        • Tsuji Y.
        • Ono S.
        • et al.
        Polyglycolic acid sheets with fibrin glue can prevent esophageal stricture after endoscopic submucosal dissection.
        Endoscopy. 2015; 47: 336-340
        • Sakaguchi Y.
        • Tsuji Y.
        • Fujishiro M.
        • et al.
        Triamcinolone injection and shielding with polyglycolic acid sheets and fibrin glue for postoperative stricture prevention after esophageal endoscopic resection: a pilot study.
        Am J Gastroenterol. 2016; 111: 581-583
        • Nagami Y.
        • Shiba M.
        • Tominaga K.
        • et al.
        Hybrid therapy with locoregional steroid injection and polyglycolic acid sheets to prevent stricture after esophageal endoscopic submucosal dissection.
        Endosc Int Open. 2016; 4: E1017-E1022
        • Ono S.
        • Fujishiro M.
        • Koike K.
        Endoscopic submucosal dissection for superficial esophageal neoplasms.
        World J Gastrointest Endosc. 2012; 4: 162-166
        • Ono S.
        • Tsuji Y.
        • Fujishiro M.
        • et al
        An effective technique for delivery of polyglycolic acid sheet after endoscopic submucosal dissection of the esophagus: the clip and pull method.
        Endoscopy. 2014; 46: E44-E45
        • Takimoto K.
        • Toyonaga T.
        • Matsuyama K.
        Endoscopic tissue shielding to prevent delayed perforation associated with endoscopic submucosal dissection for duodenal neoplasms.
        Endoscopy. 2012; 44: E414-E415
        • Mellow M.H.
        • Pinkas H.
        Endoscopic laser therapy for malignancies affecting the esophagus and gastroesophageal junction. Analysis of technical and functional efficacy.
        Arch Intern Med. 1985; 145: 1443-1446
        • Isomoto H.
        • Yamaguchi N.
        • Minami H.
        • et al.
        Management of complications associated with endoscopic submucosal dissection/ endoscopic mucosal resection for esophageal cancer.
        Dig Endosc. 2013; 25: 29-38
        • Iizuka T.
        • Kikuchi D.
        • Yamada A.
        • et al.
        Polyglycolic acid sheet application to prevent esophageal stricture after endoscopic submucosal dissection for esophageal squamous cell carcinoma.
        Endoscopy. 2015; 47: 341-344
        • Kataoka Y.
        • Tsuji Y.
        • Sakaguchi Y.
        • et al.
        Preventing esophageal stricture after endoscopic submucosal dissection: steroid injection and shielding with polyglycolic acid sheets and fibrin glue.
        Endoscopy. 2015; 47: E473-E474
        • Freund M.R.
        • Spira R.M.
        • Reissman P.
        Severe esophageal dilation causing central airway obstruction: a rare complication of LAGB.
        Surg Obes Relat Dis. 2017; 13: e13-e15

      Linked Article

      • Stricture prevention after esophageal endoscopic submucosal dissection
        Gastrointestinal EndoscopyVol. 92Issue 6
        • Preview
          Over the past 2 decades, there has been a paradigm shift in the treatment of early esophageal cancer. Previously, esophagectomy was favored, but with advances in endoscopic technique, the morbidity and mortality of surgery could be avoided in most cases, and endoscopic resection rapidly became the preferred treatment modality. Initially, EMR allowed for en bloc resection of small tumors or piecemeal resection of larger lesions. Now, endoscopic submucosal dissection (ESD) allows for the en bloc resection of even very large superficial tumors.
        • Full-Text
        • PDF